your future face - dr. dennis gross, md future face “with all the products out ... published by...

By the Founder of mdskincare

D E N N I S G R O S S , M . D .

with Cara Kagan

C r e a t e a C u s t o m i z e d P l a n

f o r B E A U T I F U L S K I N

C h o o s e t h e A N T I A G I N G

T r e a t m e n t O p t i o n s T h a t

A r e R i g h t f o r Y o u

YOUR FUTURE FACE

“With all the products out there, what’s a girl to do? Dr. Gross is amazing and he has the answer.” —PLUM SYKES, author of Bergdorf Blondes

Author photo by Jeffrey Weir

ISBN 0-452-28718-9

Title Your Future Face

9

780452 287181

51500

EAN

U.S.A. $15.00CAN. $21.00

THESE DAYS, WE’RE BOMBARDED with advances in skin care that promise to turn back the clock and restore our gorgeous, younger-looking skin. Not all treatments work for everyone, and choosing the right products and procedures is more confusing than ever. In Your Future Face, Dr. Dennis Gross, one of the country’s leading dermatologists and founder of the renowned M.D. Skincare® product line, offers an individualized program that will prevent damage, repair, and dramatically enhance the youth and beauty of your skin at any age.

Your Future Face begins with a simple “Skin Lifecycle Quiz” that assesses your skin’s specific vulnerabilities and predicts your future aging pattern. Once you’ve determined your goals, Dr. Gross provides a customized antiaging plan and invaluable advice, including:

Proven antiaging ingredients you can find in affordable products Simple, yet effective nutritional and lifestyle tips How to naturally boost your skin’s firming proteins Whether to use Botox and how to do it safely How to choose the injectable wrinkle filler that is right for you New breakthroughs in noninvasive peels and lasers,

and the benefits of deeper treatments Plastic surgery: pros, cons, and how to avoid it

Treasured by celebrities and beauty insiders alike, Dr. Gross’s unique methods offer the safest and most effective program for your best skin ever.

For more information, visit www.yourfutureface.com

“I only wish my face had read Your Future Face earlier. Read it and get the skin you’ve always dreamed of!” —JOAN HAMBURG, WOR Radio

DEN

NIS G

RO

SS, M.D

.Y

OU

R FU

TUR

E FACE

PLUME

A PLUME BOOKBeautywww.penguin.com

TITLE: 5.5 x 8.4375 SPINE: 0.4375TITLE: 5.5 x 8.4375 SPINE: 0.4375

a plume book

YOUR FUTURE FACE

dennis gross, M.D., is a practicing New York City dermato-logist, dermatological surgeon, and skin-care expert with an ex-tensive background in skin and biomedical research at MemorialSloan-Kettering and Rockefeller University. He is a clinician atNew York University Medical Center, where he received his med-ical degree and dermatological training, and he is the founder ofM.D. Skincare, a comprehensive line of skin-care products. Dr.Gross has many high-profile clients, and he has been featured inpublications such as Elle, Glamour, Cosmopolitan, and Vogue.

cara kagan, a writer and consultant on beauty and fitness formore than twelve years, has been the beauty and fitness director atseveral magazines, including Elle.

Your Future FaceCreate a Customized Plan for Beautiful Skin

yD E N N I S G R O S S , M . D . ,

w i t h C a r a K a g a n

A PLUME BOOK

PLUMEPublished by the Penguin Group

Penguin Group (USA) Inc., 375 Hudson Street, New York, New York 10014, U.S.A.Penguin Group (Canada), 90 Eglinton Avenue East, Suite 700, Toronto, Ontario, Canada

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Penguin Books Ltd., Registered Offices: 80 Strand, London WC2R 0RL, England

Published by Plume, a member of Penguin Group (USA) Inc. Previously publishedin a Viking edition.

First Plume Printing, January 2006

1 3 5 7 9 10 8 6 4 2

Copyright © Dennis Gross, 2005All rights reserved

registered trademark—marca registrada

CIP data is available.ISBN 0-670-03371-5 (hc.)

ISBN 0-452-28718-9 (pbk.)

Printed in the United States of America

Without limiting the rights under copyright reserved above, no part of this publication may be re-produced, stored in or introduced into a retrieval system, or transmitted, in any form or by anymeans (electronic, mechanical, photocopying, recording or otherwise), without the prior writtenpermission of both the copyright owner and the above publisher of this book.

PUBLISHER’S NOTE: Every effort has been made to ensure that the information containedin this book is complete and accurate. However, neither the publisher nor the author is engagedin rendering professional advice or services to the individual reader. The ideas, procedures, andsuggestions contained in this book are not intended as a substitute for consulting with your physi-cian. All matters regarding your health require medical supervision. Neither the author nor thepublisher shall be liable or responsible for any loss, injury, or damage allegedly arising from any in-formation or suggestion in this book.

The scanning, uploading, and distribution of this book via the Internet or via any other meanswithout the permission of the publisher is illegal and punishable by law. Please purchase only au-thorized electronic editions and do not participate in or encourage electronic piracy of copy-righted materials. Your support of the author’s rights is appreciated.

books are available at quantity discounts when used to promote products or services.for information please write to premium marketing division, penguin group (usa) inc.,375 hudson street, new york, new york 10014.

To my wife, Carrie, whose beauty and joie de vivre

are my inspiration. And to my children,

Daniel, Allison, Liza, and Jonathan, who reaffirm my belief in the goodness of humanity.

A C K N O W L E D G M E N T S

Thanks to my agent, Kris Dahl, who first believed in me and foundthis book a good home at Viking. The team at Viking was un-matched in its patience and professionalism throughout this proj-ect and I’d particularly like to thank my editor, Janet Goldstein,for her insights and encouragement. Thanks also to my cowriter,Cara Kagan, for her enormous contribution.

Caren Feingold also provided invaluable help with the nutri-tional information for this book, and Susanna Romano at AKSSalons for her tips on hairstyle and makeup.

Special thanks go to all my professors and mentors at NewYork University Department of Dermatology, Memorial Sloan-Kettering Institute, Wesleyan University, and Rockefeller Univer-sity, who taught me the science of skin and to think analytically.

C O N T E N T S

A C K N O W L E D G M E N T S vii

1 TA K I N G C H A R G E O F Y O U R S K I N 1

2 C R E AT I N G Y O U R P E R S O N A L P R O F I L E 11

3 Level One E S S E N T I A L C A R E A N D P R E V E N T I O N 25

4 Level Two A C T I V E R E PA I R A N D P R O T E C T I O N 57

5 Level Three A G E - E R A S I N G O P T I O N S 91

6 Level Four M A J O R C H A N G E S . . . O R N O T 125

7 Beauty Bonus Points 14 S U R E F I R E L I F E S T Y L E H A B I T S F O R H E A LT H I E R A N D Y O U N G E R - L O O K I N G S K I N 153

8 T H E R E C I P E F O R G O R G E O U S S K I N 163

A C T I V E I N G R E D I E N T S C H E C K L I S TThe Essentials for an Effective Daily Antiaging Regimen 191

R E S O U R C E L I S T 197

I N D E X 203

Your Future Face

1YT A K I N G C H A R G E O F Y O U R S K I N

W e are now in what I call the Golden Age of SkinCare. There have never before been so many prod-ucts and procedures that can literally erase years off

our faces. In fact, skin care, plastic surgery, and antiaging tech-niques are now frequently the topic of newspaper and magazinearticles, TV news programs, and reality shows. Everywhere youlook, it seems, there are new miracle ingredients and proceduresdesigned to make you look younger than ever no matter whatyour age.

When it comes to turning back the clock, we are truly fortu-nate. No prior generation has had such an in-depth knowledge ofthe aging process as well as the chemistry and biological makeupof the skin. This knowledge has resulted in a dizzying number ofamazing technological breakthroughs and a cornucopia of prod-ucts and procedures that make it easier than ever to get a gorgeousand glowing complexion at any age.

But as media coverage and antiaging options have increased,it has become clear to me that many of my patients are really con-fused about what they should do for their skin. Often my patientscome in with a magazine article or an ad for a product and ask meto explain it and to advise them on whether it is right for them. Asmodern technology increases and more ingredients and therapiesare discovered, the more perplexed my patients become.

I decided that now more than ever it is crucial to clarify whatis out there to help stop this confusion so that you can take chargeof your skin and make fully educated decisions rather than relyingon the recommendations of friends, the media, and product ad-vertisements. I’ve written this book based on my sixteen years inprivate practice, the extensive research I’ve conducted in the anti-aging area, and on the published studies of other prominent sci-entists and physicians. Its purpose is to help you choose theproducts and procedures that are right for you so you can beat fa-ther time at his own game. But more than presenting you withskin-care regimens and high-tech treatments, I want to help youtap into a powerful age-fighting weapon that is innate—your abil-ity to predict how and when you are going to age and which areasare most vulnerable to its visible signs.

Sure, aging can seem like an overnight phenomenon. We go tobed one night with smooth, taut, glowing skin and wake up thenext day somehow looking older. We may ask ourselves “How didthis suddenly happen?” But no matter how much it seems like asneak attack (and can it ever!), the aging process is actually sys-tematic and predictable. And this is a beautiful thing. We havethe power to look into the future and know what we can expectin terms of how we will look as we get older. This knowledgeprovides us with the most effective way to make our skin look bet-ter than ever today and to keep it looking that way well intotomorrow.

2 Y O U R F U T U R E F A C E

The key predictors are:

� Our genetics

� How our face looks when we are expressionless

versus when it is expressing an emotion

� How we look when we are tired versus well

rested

� How our skin has been affected by the sun. Sun-

damaged skin often gets crinkles, which will

ultimately turn into wrinkles.

Paying attention to these signals helps us determine how wewill look as we get older and what areas of vulnerability we mayhave that might require a little extra TLC. And here is the bestpart: Once we know our specific aging patterns, we can take a tar-geted, results-oriented and, hence, more effective approach to get-ting beautiful, healthy, and more radiant-looking skin. And if youalready have any early signs of time etched into your face, pre-dicting their future impact will help you prevent these imperfec-tions from becoming further entrenched and even erase many ofthem.

These days, selecting the skin-care regimens and treatmentsthat will work best for us is more complicated than it was backwhen there were only day versus night creams to choose from. Inthis new era of walk-in, antiaging clinics, myriad skin-care prod-ucts and treatments available in doctors’ offices, spas, and stores,it is more important than ever to know what will help you getthe right results for your face. Further complicating the matter isthat it seems like a new wonder ingredient, product, or procedureis being introduced nearly every day. Some are actual miracleworkers—proven by bona fide scientific research—to erase andprevent the signs of time. But some haven’t yet proven themselves.

T A K I N G C H A R G E O F Y O U R S K I N 3

While this may not necessarily mean they won’t some day, Istrongly believe in going with the tried and true versus the not yetconfirmed. This book will present and explain the scope of thera-pies currently on the market to help you weed out the ones thatwill be the most effective for you. By honing in on your specificneeds, you can make the best possible decisions about the productsand treatments that will give you the best results. The truth is, to getthe benefits you are looking for, it is crucial that you use the prod-ucts and procedures that address your specific patterns of aging atthe appropriate phase of your skin’s life cycle. Even if it is an in-gredient or procedure with positive research behind it, not every an-tiaging remedy is appropriate for you now, and some may never be.

The next chapter features my “Skin Life Cycle Quiz” that willdetermine the phase of your skin’s development and your specificaging patterns. Then we will discuss the spectrum of treatmentsthat will work best for you and help you develop your most ef-fective regimen. In general, I have found that the vast majority ofmy patients get better results by starting out with milder but stillefficacious products and treatments and gradually working theirway up to stronger more aggressive ones if need be. Even if youare looking for a dramatic change, it’s important to begin withthe basics, such as wearing sunscreen and adhering to a solid dailyregimen with proven active ingredients to help your skin get intothe best possible condition it can be and then to keep it that way.Invasive procedures like face-lifts may turn back the clock, butthey don’t stop it from ticking. Time inevitably marches on. Andwhile plastic surgery may tighten sagging skin, it won’t improveyour overall complexion. Meaning if your skin is blotchy, sun-damaged, and lined before the surgery, it will still be that wayafterward.

Think of it this way. If we want to get in shape, going to thegym for the first time in years and hoisting the heaviest weights


possible and running as fast as we can on the treadmill for fivemiles will most likely cause us to become injured—not becomemore fit. Our bodies respond better if we gradually increase theduration and intensity of our exercise routines. It is the cumula-tive effects of these consistent workouts that will help us toachieve our goals—not one extreme sweat session. Skin care oper-ates in much the same way. Shocking the skin with an overly ag-gressive product or procedure can result in an injury that mayoutweigh any of its potentially positive effects. Over the years, I’vetreated hundreds of patients who’ve made enormous gains fromnonaggressive products and procedures.

The Facts on Aging SkinTo understand better how to combat the signs of aging, it’s a goodidea to become familiar with the process itself. The rate at whichour skin ages and how this aging will manifest itself are deter-mined primarily by our genetics, the passage of time, and ourlifestyles. All of these factors play a role in how we will look at anygiven moment and give us information to help predict how wewill look in the future.

O U R F A M I L Y T R E E S

Our bodies have their own internal clocks that help determinehow and when we will age. For some people, that clock ticks fasterthan others, and they look and/or feel older than their chrono-logical years. For others, it ticks more slowly, and they look and/or feel younger. This clock is set by our ancestral DNA, whichmeans there is a strong likelihood that our health and bodies, in-


cluding our skin, will have the same strengths and weaknesses asthose of our family members in much the same way as we inheriteye and hair color. Looking at the parent we most closely resem-ble and assessing how his or her skin aged can be a powerful pre-dictor of how we will look in the future (see photo section, page 2).But lifestyle habits do play a role here. For example, if a parentsmoked or worshiped the sun and you never did, your overallhealth and appearance will no doubt reap the benefits.

Knowing our inherent strengths and weaknesses lets us takethe most targeted preventative and curative measures. For exam-ple, if sagging seems to be a family trait, there are lifestyle habitswe can adopt, such as not losing a drastic amount of weight as weget older, to stave off the so-called inevitable. Our genetics alsogive us a good indication of which treatments and procedures willbe the most effective for us. For example, if family members havebeen using an ingredient successfully without irritation, there isan excellent chance that it will have similar benefits for us.

A S T I M E G O E S B Y

As we age our body’s natural functions start to wind down, in-cluding the biochemical mechanisms that keep skin looking itsbest. Our skin has built-in natural defenses to protect it fromdamage, be it from a bad sunburn, drinking too much alcohol,not sleeping enough, and a host of other things. Skin also hasamazing regenerative abilities that help it repair any damage itmay have incurred. But our skin also has natural enzymes thatbreak it down. As we age, our skin’s defensive and healing powersno longer outpace its natural degradation process. The net resultis that our skin loses its ability to fend off and recover from inter-nal and external stressors.

Here’s another fitness analogy. A young jogger can go out one


day and pound the pavement. Her knees might be a bit sore af-terward, but the next day she can get up and jog again withoutany major problems. An older jogger, whose knees have taken thistype of stress for years, has less natural protection against this typeof trauma and less than optimum regenerative abilities to help re-pair the damage her joints may have sustained during her after-noon run. She will most likely not be able to handle that kind ofbeating two days in a row without having aching knees. Our skinis no different. As we age, routine stresses, like the sun or lack ofsleep, become more traumatic to our skin because we have fewernatural defenses to come to its aid. But here’s where modern sciencesteps in, bringing with it a host of protective and reparative prod-ucts that can take over where our own natural functions have left off.

W E A R A N D T E A R

When we buy a pair of new shoes, the leather is smooth, even incolor, and blemish-free. But as we wear them, they start to de-velop creases. In the beginning, these creases are only visible whenwe are walking. But the more we walk in the shoes, the deeper thecreases get until they are visible all the time. Our skin is kind oflike that. The more we use it, the less “new” it appears. And weuse our skin a lot. Our many years of making repetitive facialmovements, for example, are a key cause of lines. If, let’s say, wehave a tendency to furrow our brows, our faces may “freeze thatway,” as our mothers might have said. Well, not exactly but close.What happens is that by constantly creasing our foreheads, wecan tax the skin to the extent that its ability to bounce back be-comes compromised. Gradually a wrinkle will form as a result,even when we are not furrowing (see photo section, page 3).But again, these creases don’t have to be permanent. There areproven ways to relax them back either to their former smooth


state or very close to it. Plus, there are many lifestyle habits wecan adopt that will prevent further wear and tear and even reversesome of the signs of it. The sun, wind, not sleeping enough, eat-ing an unhealthy diet, and many other habits do show up on ourfaces. By making certain changes in our daily routines, we notonly can improve our overall health but also the condition of ourskin.

Genetics also comes into play here, though. Some people aremore predisposed than others to particular stresses. Think of thatannoying friend who lives on cheeseburgers and fries yet remainssuperthin and doesn’t develop high blood pressure. Once we fac-tor in genetics with our skin’s natural aging process and our lifestylehabits, we can develop a precise and targeted strategy that will putus on the path (and keep us there) to amazing-looking skin.

Amazing-looking skin, however, can be a completely subjec-tive term. How we feel about the way we look plays a significantrole when we are trying to determine an appropriate course of ac-tion. In my experience, a person who is happy with their appear-ance is pleased with making slow and steady improvements, evenif others might say she needs a more speedy and radical approach.On the other hand, a person who is very critical of their appear-ance is often tempted to take more extreme measures in the hopesof making a dramatic difference, whether or not the condition oftheir skin calls for it.

But no matter how you feel about your skin, it is importantto remember that permanent procedures such as a face-lift aren’treversible. And other invasive measures, such as laser resurfacing,which can be appropriate for some people, can leave lasting scarsand skin discolorations.

Your first step to beautiful, younger-looking skin is to take allof these elements into account: your genetics, lifestyle, inheritedpatterns of aging, your skin’s present condition, and the way you


feel about your appearance so that you can make educated deci-sions about which products and therapies will work for you. “Creat-ing Your Personal Profile” will help us determine your skin’s level(phase of its life cycle) by factoring in all of the above. Your score willhelp you map out your personalized plan of products and perhapsprocedures that will best work for you to give you the results thatyou want. Every level, however, does need to start out with the basicpreventative measures and healthy skin-care habits outlined in chap-ter 3, “Level One: Essential Care and Prevention.” Each successivechapter level will provide progressively more intensive measures thatwill yield more dramatic results. The important thing to remember,however, is that you don’t have to get more aggressive and invasive ifyou are satisfied with the results you are getting and/or are just plainuncomfortable with the idea of elective cosmetic surgery or a pro-cedure that requires substantial recovery time. It is your face, after all.

The last two chapters will focus on the lifestyle and nutritionalhabits that will make all the difference in the world to the way youlook and feel—no matter what your level.

So with all this in mind, let’s get started and give you the knowl-edge and the tools that will give you your best skin ever.


2YC R E A T I N G Y O U R P E R S O N A L P R O F I L E

T o help you develop your most effective regimen possible,I’m going to ask you to sharpen your diagnostic tools, mostof which you already have. You’ll start by determining the

phase of your skin’s development with “The Skin Life CycleQuiz” and then you’ll zero in on your specific areas of vulnerabil-ity by assessing the way you look now and by using the built-inage predictors specific to your face: your genetics; how your facelooks when you are expressionless versus when you are expressingan emotion; how you look when you are tired versus well rested;how you’ve been affected by the sun so far—the crinkle-before-the-wrinkle test (see photo section, page 2); and your subjectivefeelings about your skin.

Then you will be armed and ready to take the most effectiveactions to treat your skin’s exact conditions. You, not the label ona product, a facialist, friend, or the media, will design the regimenthat will give you younger, healthier, and more beautiful skin.

The Skin Life Cycle Quiz

I developed a quiz so my patients and I are better able to zero inon which specific aspects of their appearance they would like tochange and to what extent, what their inherited patterns of agingare, and how they really feel about the way that they look. Thesequestions take into account four of the key components that helpforecast how and when our skin will age.

How you score on this quiz will help you to determine theoverall condition of your skin, or your level. Once we’ve figuredthat out, we will focus on the quiz’s specific questions that will letus diagnose the areas or conditions that you might want to pay ex-tra attention to. We will then customize the regimen of products,possible procedures, and lifestyle changes that will give you thebest results in the most efficient and least invasive way.

The important thing to remember is that there is no suchthing as being too young to start taking preventative measures or,conversely, having skin that is too far gone to make a difference.No matter what condition your skin is in, adopting solid, basicskin-care habits, a healthy diet and lifestyle, protecting yourselffrom the sun, and using the proven antiaging ingredients gearedto your needs will make all the difference in the world—not onlytoday but also for tomorrow. And if you decide you’d like to domore than the basics, knowing your level and specific areas ofvulnerability will help you to sort through the hundreds of prod-ucts and procedures on the market to determine the antiagingstrategy that’s best for you. With that in mind, rest easy in theknowledge that in this quiz, there is no such thing as a wrong an-swer. It is crucial that you respond to the questions as accurately


and as honestly as possible, so you can find a safe and effectiveskin-care plan that is right for you.

Choose the single best answer for each of the following ques-tions. And if you are currently receiving any treatments for correc-tion of facial wrinkles (such as Botox or fillers), then answer thequestions considering how your face would look without thesetreatments.

1. How often do you think about the way your face looks?

A. Once a day

B. Three times a day

C. It’s almost always on my mind

2. Your past experience with the sun is:

A. You never burned

B. You burned as a child and/or tanned as a teen

C. You have burned in the past and already have had a

skin cancer or precancer

3. If you did not wear sunscreen and sat out in the sun, you would:

A. Tan immediately

B. Turn red, then tan

C. Most likely burn

4. Now that you’re an adult, when you’re outdoors you:

A. Always wear at least an SPF 15

B. Wear an SPF 15 but switch to a lower SPF once you’re

tan

C. Use an SPF 8 or less

C R E A T I N G Y O U R P E R S O N A L P R O F I L E 13

5. When the family member you most closely resemble was your age, he or

she looked:

A. Much worse than you do now

B. Worse than you do now

C. Better or the same as you do now

6. (If you are female, answer this question in terms of your mother; if you are

male, in terms of your father.) How did your mother or father’s skin age?

A. Fabulously

B. Acceptably

C. Not well at all

7. Your overall feeling about your skin is:

A. You are happy with the way that it is

B. You are generally happy but there are one or two

things that are starting to bother you

C. There are a number of things that you’d like to change,

and you’re looking for fairly dramatic results

8. You can honestly say that when it comes to leading a healthy lifestyle

you:

A. Regularly eat right, get enough sleep, and exercise

B. Regularly do two of the above

C. Regularly do one or none of the above

9. When you’re tired your face:

A. Looks the same as when you’ve had a good night’s sleep

B. Has under-eye circles

C. Has under eye-circles and bags

10. How much do you smoke now or did you smoke in the past?

A. You do not smoke and never have


B. You smoke (d) one to four cigarettes daily

C. You smoke (d) five or more cigarettes every day

11. How much alcohol do you drink?

A. Scarcely any

B. Enough so that it affects your sleep once or twice a

week

C. To intoxication once a week or more

12. Your forehead shows:

A. Two lines across it when you raise your eyebrows

B. More than two lines across it when you raise your eye-

brows

C. Lines across it even when you don’t raise your eye

brows

13. You think your forehead:

A. Looks fine but you want to prevent it from aging

B. Is okay for now but will probably start to show the

signs of wear and tear in one to three years

C. Needs work to make you happy with it

14. The skin around your eyes (crow’s-feet area) shows:

A. One to two lines when you smile

B. More than two lines when you smile

C. Lines even when you’re not smiling

15. You think the skin around your eyes:


B. Is okay for now but will probably start to show signs of

wear and tear in one to three years

C. Could stand some noticeable improvement


16. Which of the following statements is most true about your eyelids?

A. Nothing bothers you about either the upper or lower

eyelids

B. You are bothered either by wrinkles on the lower lid or

laxity of the upper eyelid

C. You are bothered by both wrinkles on the lower eyelid

and laxity on the upper eyelid

17. You think your eyelid skin:


B. Is okay for now but will probably start to show some



18. Aging skin around the mouth changes in three ways: The creases

deepen, the upper lip forms wrinkles, and the lips lose their plumpness.

Which is true for you?

A. None of the above

B. One of the above

C. Two or three of the above

19. You think the skin around your mouth:





20. You neck skin is:

A. Firm and does not bother you

B. Shows some laxity

C. Sags too much


21. You think your neck:





22. The skin on the back of your hands:

A. Is firm and does not bother you

B. Does not bounce back quickly after you pinch and re-

lease it

C. Sags too much

23. You think your hands:

A. Look fine but you want to prevent them from aging

B. Are okay for now but will probably start to show some



Calculating your final score

Follow the directions below, especially those in bold.


Count thenumberof times youselected answer A. Enter that numberin the box below.

Count thenumberof times youselected answer B.Multiply it by 2.Enter that numberin the box below.

Count thenumberof times youselected answer C.Multiply it by 3.Enter that numberin the box below.

Add the numbers in the 3 boxes above:

If you are 33 years old or older enter 5 here:Add the circled numbers together for your final score:

F I N A L S C O R E

(A score of 23–34) Level One: Essential Care and Prevention

I call this phase in your skin’s life cycle Invisible Aging becausewhile your skin may appear youthful and beautiful on the surface,deep down below it’s already starting to age. “Level One: EssentialCare and Prevention” will help you plan out a customized plan ofsound daily skin care and lifestyle habits, plus identify the prod-ucts that will help keep you looking fabulous longer and preventthose invisible signs from surfacing. The “Level Two Active Re-pair and Protection” chapter will outline some slightly more ag-gressive preemptive and curative measures that you may want totake as your skin progresses to the next level. These treatmentsalso may be relevant if you feel like you have one or two issuesthat seem to be “older” than the rest of your face or a strong ge-netic tendency toward something you’d rather not be faced with;e.g., deep lines in the crow’s-feet area. At this phase, you shouldn’teven think about doing any major corrective or preventative mea-sures for at least the next one to three years or even more. Retakethis quiz in six months to a year to chart your progress and to en-sure that your regimen is effective.

(A score of 35–46) Level Two: Active Repair and Protection

At this point, you are starting to see what I call Surface Signs—meaning some of the aging that was going on down below is nowvisible. But while your skin is starting to undergo some changes,you feel good about the way you look overall. It’s important for


you to maintain these positive feelings about yourself, no matterhow much pressure the media and/or peers exert(s). Now is notthe time to pull out any of the big guns and go for any major orpermanent procedures, such as a deep acid peel, laser resurfacing,or plastic surgery. You’ll begin with “Level One: Essential Careand Prevention” to map out your basic skin-care regimen to helpprevent further damage and reverse some of what you’ve alreadyincurred. The good news? These measures might be all that youneed to get the skin you’ve always wanted. If you want to besomewhat more assertive in preventing and/or in correcting anyissues that are bothering you, turn to chapter 4, “Level Two: ActiveRepair and Protection,” which will explain the menu of slightlymore aggressive proactive and corrective options available to youand help you to choose which one(s) will give you the best results.Chapter 5, “Level Three: Age-Erasing Options,” will reveal somemore intensive ways to handle the areas that seem to be agingfaster than the rest of your face and/or some other tactics you maywant to consider taking as you progress to the next level. Retakethis quiz in six months to a year to chart your progress and to en-sure that your regimen is effective.

(A score of 47–58) Level Three: Age-Erasing Options

Your skin is now in a phase where you will notice what I call DeeperDamage. For this reason, you would like to make some changes—perhaps even some fairly dramatic ones. You may have an overallscore of Level Three, but on further analysis your face may haveone significantly worse area (your eyes, for example) while the restof your face is Level Two. Many people are a combination of lev-els (see “Aging Patterns of Different Facial Areas” in the photosection). But the world is still your oyster and the opportunitiesabound for getting and maintaining healthier, younger-looking,


and more glowing skin. I recommend starting with the basics andthen gradually working your way up the ladder in terms of ag-gressiveness, if need be. Little changes can still make a huge dif-ference. You’ll begin with “Level One: Essential Care andPrevention” to learn your basic antiaging regimen and to find outthe lifestyle changes you can make to put you on the path to a ra-diant complexion. “Level Two: Active Repair and Protection” willintroduce the more intensive defensive and offensive measuresthat will make more noticeable and dramatic improvementswhen used in tandem with an effective daily skin-care regimen.Should you still want to turn up the heat, “Level Three: Age-Erasing Options” will explain all of the more aggressive antiagingprocedures, help you weigh their promised benefits against theirrisks, and outline when and in what combination they might workbest for your needs. “Level Four: Major Changes . . . Or Not” willevaluate some of the ways you can treat the areas that seem to beaging faster than the rest of your face, and how to plan accord-ingly. Retake this quiz in six months to a year to chart your progressand to ensure your regimen is effective.

(A score of 59 plus) Level Four: Major Changes . . . Or Not

At this level, your skin is at what I call the Advanced Aging stage.This might mean that there are many things about your appear-ance you’d like to change significantly. But now is not the time topanic and seek out the most extreme measures. “Level Four: Ma-jor Changes . . . Or Not” does give you a suggested timelinefor using the more aggressive age-beaters, including cosmeticsurgery, if you want more of a dramatic change. Again, while youroverall score is Level Four some of your face may only be a LevelThree or even Level Two! But good daily skin-care habits, provenantiaging ingredients, and diligent use of sunscreen are still im-


portant parts of your regimen, no matter which procedure orsurgery you may choose to undergo. There is also a wide array ofnoninvasive in-office treatments that can also help you make no-ticeable and positive changes. Review the strategies in Levels Oneto Three to see which options will give you the best results withinyour comfort level.

Your Visible Signs of Aging—Do You Have Problem Areas?

Now that you’ve determined your level, let’s zero in on your par-ticular areas of vulnerability. If any of these problems are alreadyvisible and they bother you, place a check mark next to them.These are the issues to which you might want to consider giving alittle extra TLC, in addition to following a good skin-care regi-men and leading a healthy lifestyle. This way, we can fine-tune theprecise plan of attack that will be the most effective for you. I willaddress treatment for these issues at each level moving from theleast invasive therapies to the most dramatic ones.

T H E V I S I B L E S I G N S O F A G I N G

Wrinkles

Lines

General laxity

Sagging around the jaw and neck

Brow furrows

Eye wrinkles or crow’s-feet

Bags under the eyes


Slack upper eyelids

Lines on the forehead and/or from the nose to the

mouth

Pigmentation spots

Broken capillaries

Enlarged pores

Your Aging Patterns: What Problems Can You Predict and Minimize?

You can forecast the areas of concern that are not yet visible butmay crop up later on in life. As you read through the factors be-low, make a note of the particular risks that seem to apply to you.

O U R G E N E T I C S ( P H O T O S E C T I O N , P A G E 2 )

Looking at the parent you most closely resemble literally can serveas a blueprint for the way we will most likely look when we areolder. Is there a family trait? Are there any signs of aging, such asbrow furrows, crow’s-feet, or under-eye bags that nearly everyoneseems to have? Looking beyond what we see in the mirror todayand at the older face that’s most like ours can forecast how we willlook tomorrow. But don’t forget that lifestyle habits can have aprofound affect here, as well as speeding up or slowing down theaging process. One of my daughters, for example, has had frownlines in between her brows when she scowls or concentratessince practically the day she was born. They’re inherited from her


family. But knowing this is her area of vulnerability will help herto prevent them from becoming more entrenched. Practical ad-vice I’ll give my daughter is to diligently wear sunglasses to mini-mize her scowling in the sun. This will help prevent permanentcreasese between her brows to which she is predisposed.

H O W Y O U L O O K W H E N Y O U A R E

E X P R E S S I O N L E S S V E R S U S

W H E N Y O U A R E E X P R E S S I N G A N E M O T I O N

( P H O T O S E C T I O N , P A G E 3 )

In a sense, year after year of repetitive facial movements act like astressor to the skin. There is a strong possibility that the lines orfurrows that only appear when we squint, for example, may be-come permanent later on in life. These areas reveal our face’sweakest links—the places that are selectively vulnerable becausethey experience and have experienced the most stress.

H O W Y O U L O O K W H E N Y O U ’ R E T I R E D V E R S U S

W E L L R E S T E D ( P H O T O S E C T I O N , P A G E 2 )

Do you have dark circles? Puffy under eyes? Does your face seemmore slack or pinched? How we look when we are tired today alsocan be a predictive mirror of what our faces may look like tomor-row even when we aren’t tired. The reason? When we are youngerand well rested our body is essentially running on a full tank ofgas—meaning our reserves and regenerative abilities are at opti-mum levels. At the end of the day, as our tank becomes depleted, ifwe get a good night’s sleep, we wake up on full. One or two sleep-less nights don’t necessarily affect our appearance because our re-serves are strong enough to survive a few days without refueling.


As we mature, our skin’s reserves are more easily depleted andso we temporarily look older when we don’t get enough rest. Theareas of our face that appear more aged as a result reflect our areasof vulnerability. They can reveal what we may look like once wehave exhausted our reserves. When we are older, no matter howmuch sleep we get, we still have fewer reserves and regenerativeabilities so we may end up looking tired all of the time, even whenwe aren’t.

H O W Y O U R S K I N H A S B E E N D A M A G E D

B Y T H E S U N — T H E C R I N K L E - B E F O R E -

T H E - W R I N K L E P R I N C I P L E

( P H O T O S E C T I O N , P A G E 2 )

Areas of skin that appear crinkly though not quite lined or wrin-kled, either all the time or just after a pinch is released, generallyindicate areas that have sustained more sun damage than the restof the face or the body. The chest, eye area, and hands are especiallyvulnerable to crinkling. Over time, there is a strong possibility thatthese regions will morph into lines, or wrinkles, or start to sag.

Now go back to the list of “The Visible Signs of Aging,” page21, and place an X next to the issues that haven’t yet appeared butseem likely to. Anything with an X or a check mark are your spe-cific areas of vulnerability, which are addressed for each skin levelthroughout the book.

We will now start at the beginning. Whatever your age andcurrent skin-care approach, I have found that it’s invaluable toput together the right state-of-the-art regimen. It will help yourskin live up to its full potential of health, radiance, and beauty,minimize and sometimes even eliminate the need for more in-volved treatments, and help your skin derive the maximum bene-fits from any products or procedures you decide to use.


3Level Oney

E S S E N T I A L C A R E A N D P R E V E N T I O N

For the most part, my Level One (a score of 23–34) patientsare in skin heaven. Most of them have banished any of theblemishes they may have had in high school and/or college,

though some are still prone to breakouts that only seem to occurmid-menstrual cycle. Their skin is taut, smooth, unlined, and fairlyradiant. They are generally in their twenties to midthirties, and anyconcerns they have are fairly minor—a few sunspots here, perhapsa cluster of broken capillaries there. If you are in Level One, youprobably haven’t yet moved into the phase where the more serioussigns of sun damage have appeared, though there may be crinklingwith the tiniest hint of crow’s-feet or the faintest forehead furrow.

My mantra for Level Ones is the tried but true: “an ounce ofprevention . . .”—well, you know the rest. The thing about skinat this phase is that even if it appears unmarred on the surface, itcan be undergoing changes deep down inside that will start to af-fect its appearance not too far down the road. Credible scientific

research shows that as early as age twenty-five our skin’s two struc-tural proteins—collagen (which keeps it firm, taut, and resilient)and elastin (which gives skin its flexibility, enabling it to stretchout and then snap back into place)—decrease. Futhermore, cellturnover slows, antioxidant protection diminishes, and natural de-fenses and skin-healing abilities decline. Not to sound dramatic,but here is the reality: You may not be able to see lines or wrinklesor sagging, but they are there hiding below the surface; and theywill, not long from now, start to become visible.

But enough doom and gloom. The good news is that we can,in fact, fight Mother Nature and even finesse our genetics in someways. During the last decade an exciting number of ingredientsand treatments have proven themselves to be effective in slowingdown our skin’s natural aging process, and even reversing some ofits signs. Your skin can look fabulous longer than we’ve everthought possible, and you can face the coming years ahead farmore beautifully than anyone ever imagined.

The BasicsYour plan of attack is to protect your skin from further damage,to prolong its present youthful state, and to prevent those signs ofaging from surfacing for as long as possible. And you can do all ofthe above by incorporating just a few essential practices and activeingredients—with documented evidence behind them—into youreveryday life. These habits will not only significantly improveyour skin’s health and appearance today but also guarantee that itwill look firm and radiant in the future.

26 L E V E L O N E

1 . A S S E S S Y O U R S K I N T Y P E

I frequently see Level One and even Level Two patients who con-tinue to use the same harsh cleansers and drying astringents theyrelied on when they were oily and acne-prone teenagers. Whilethese products won’t age skin, they can compromise its health andappearance. You may not feel or see it, but at this phase in yourskin’s life cycle, your oil glands are starting to shrink so they startto produce less sebum. This can make antiacne and mattifyingproducts that were once effective cause redness, flaking, and irrita-tion. Logically, you might try to alleviate this discomfort by switch-ing to a heavier moisturizer or applying one more frequently but,unfortunately, this seemingly appropriate remedy only exacerbatesthe problem. Level One skin is particularly prone to breakouts, aswell as clogged and/or permanently enlarged pores, that can occurfrom moisturizing overkill.

Dried-out skin also may try to rebound and produce even moreoil to lubricate itself. This can lead to more blemishes, which mayprompt you to use even stronger drying agents in an attempt toclear them up. Alcohol-based products, especially, are notorious

E S S E N T I A L C A R E A N D P R E V E N T I O N 27

When Cost CountsWhen it comes to skin care, money may buy more effectivehigher tech or medical-grade ingredients that justify the pricetag, but not always. Some expensive sunscreens, for example,contain the same basic ingredients as the cheaper ones. But ingeneral, the more expensive products are more esthetically pleas-ing to use in terms of their texture, scent, and packaging.

for causing this boomerang effect. Using them may also lead tothe hyperirritation that can cause the formation of broken capil-laries and exacerbate rosacea and eczema.

If the use of antiacne products is drying out your skin, or ifyour skin is simply becoming drier on its own, first try using amilder cleanser (e.g., one that is labeled for NORMAL/COMBINA-TION or SENSITIVE skin instead of one for OILY or BLEMISH-PRONE,skin) before you switch to a more emollient moisturizer or start touse a moisturizer more frequently. Also, if you use a toner, tryswitching from an alcohol-based product to one that containswitch hazel. The extract from this plant has a proven astringent,toning, and anti-inflammatory effects. It also dissolves excess se-bum without stripping skin. I purposely formulated M.D. Skin-care’s cleanser with witch hazel as research shows it has all of thesebenefits without the potential side effects of alcohol.

If you’ve taken these measures and your skin is still dry andtight, the best way to soothe it without causing additional break-outs is to use a moisturizer that is labeled OIL FREE. These lotionsincrease the water content of skin without adding extra oil, sothey won’t aggravate or cause acne. Start by applying the mois-turizer once a day and then trade up to twice daily if you need it.Believe it or not, products that are labeled with terms like NON-COMEDOGENIC, HYPOALLERGENIC, FOR ACNE-PRONE SKIN, andWON’T CLOG PORES that suggest they do not cause breakouts cancontain oil, which can clog pores and cause blemishes.

If your skin is dry in certain areas, such as the cheeks, but con-tinues to be oily in others, such as your forehead, nose, and chin(also known as the T-zone), you can remedy the situation by ap-plying a basic moisturizer on just the spots that are dry or by us-ing a “self-adjusting” formula on your whole face. This type ofproduct contains special moisturizing ingredients that only clingto dry areas.

28 L E V E L O N E

2 . R E V U P C E L L R E N E W A L : D A I L Y E X F O L I A T I O N

A healthy rate of skin cell renewal, also known as cell turnover, is oneof the key components of radiant and even-toned skin. When we areteenagers, dead skin cells slough off when they are supposed to, sowe don’t typically develop any flaky, dead-skin buildup that can dullour complexions. Throughout our twenties and thirties, however,surface cell turnover starts to slow down from about every twenty-eight days in our teens to roughly thirty-five days at age thirty-five.While a seven-day lag may not seem like much, it can take its toll onskin. An accumulation of dead cells makes skin thicker, rougher, andprevents it from appearing radiant. But giving sluggish cell turnovera booster shot is a breeze; it merely requires some daily exfoliation.To avoid irritation, I recommend starting with the mildest methodand then gradually working up to stronger ones only if necessary.

Cleansing with a fresh washcloth with a very light pressureand circular motions might be all you need to gently remove mostdead-skin cells. (PLEASE NOTE that using the same washcloth morethan one time may lead to breakouts and irritation because clothscan harbor bacteria and mold.) The next step up would be to usea witch hazel–based toner once a day, which will work a littleharder than the cloth to exfoliate.

If your skin still appears dull, you can add a little more oomphin your exfoliation regime by using a moisturizer, gel, or serum withbeta hydroxy (salicylic acid) and/or alpha hydroxy acids. Bothtypes of acids work by weakening the links between cells in theouter layers of dry skin to allow the normal shedding process tooccur at a more optimum rate. They may also play a role in build-ing skin-firming collagen and elastin, especially when incorpo-rated into a two-step chemical peel. Alpha hydroxy acids include:lactic (from dairy products), glycolic (from sugar), malic (fromapples), and citric (from citrus fruits.) Salicylic acid is synthetic


30 L E V E L O N E

but close to the molecular structure of an acid that occurs natu-rally in skin, making it generally nonirritating. It is the only betahydroxy acid currently used in skin-care products. In my researchI have found that lotions and creams with several different kindsof acids are the most effective and least irritating because whenmany different acids are combined, each one can be used in alower (i.e., milder) concentration.

As far as manual exfoliants, such as scrubs with granules orsloughing sponges, are concerned, I find that many people over-use them and/or scrub too vigorously. But when used carefullyand as directed, they can be effective. If you like using a scrub,look for one that contains perfectly round smooth polyethylenebeads, which are gentler than seeds, nuts, husks, or pits.

3 . G O O N T H E D E F E N S I V E :

P R E V E N T S U N D A M A G E

It’s no secret that the sun is our skin’s worst enemy when it comesto causing signs of premature aging. Its ultraviolet rays are themost active culprits in triggering free radicals. These highly de-structive, corrosive, and electrically charged molecules are a lead-ing cause of everything from heart disease to arthritis. In the caseof skin, free radicals are like little darts that poke holes in our col-lagen and elastin. Eventually, free radicals corrode these stucturalproteins—literally eating away their integrity. Think of how rustymetal starts to crumble after a certain point.

Getting in the habit of wearing sunscreen with an SPF 15 orhigher every day, even when you are not planning to spend a lotof time outdoors, is a surefire way to help prevent free radicals fromforming and can prevent the damage they cause. Research showsthat a substantial amount of premature aging comes from inci-dental sun exposure when we’re unaware of it—such as when


Sunscreen 101Even the most religious sunscreen users can damage their skinbecause of some simple oversights. Here are a few new goldenrules for practicing safe sun:

1. Wear It Every Day, Even in Winter

Since sun damage can occur during even short periods of sun ex-posure, it’s a great idea to make applying it every morning secondnature, like brushing your teeth or combing your hair. And whilethe sun may feel its strongest in July and August, it is possible tosustain sun damage all year-round, even on cloudy days. And ifthere is snow on the ground, it can increase the chance of sun dam-

we’re out shopping or even grabbing lunch. Wearing sunscreenevery day will help to prevent the signs of premature aging.

Maeve,* twenty-three, had very fair skin with sunspots and achronically pink nose—the result of sun damage. Maeve came tome because she was unhappy that she had so many freckles, but Iwas more concerned by her nose. Skin that is chronically pinktypically has undergone damage to its DNA and may be prone toskin cancer. While Maeve did wear SPF 15, she wore it sporadically,and she wasn’t applying enough of it when she did. We increasedher daily sunscreen to SPF 30 and improved her applicationhabits—making sure she used enough and covered sufficient groundwith it. Now both of us are happy. Because she isn’t continuallycausing more damage, her freckles are much fainter and her nosefar less pink. The lesson here is that when you stop making some-thing worse, the skin can heal itself and look better naturally.

*The name has been changed.

32 L E V E L O N E

age because it reflects the sunlight on the ground back up to yourface, in much the same way as the sand on the beach. The sun’s ul-traviolet rays also can, to some degree, penetrate glass, so unless thewindows are specifically treated with UV protection, you can incursun damage sitting in front of the window of your sun-filled livingroom, in your office, driving your car, and on an airplane.

2. Go Broad and Go Higher

The most beneficial sunscreens are broad spectrum. This meansthey offer protection against UVA and UVB rays, which areboth detrimental to skin. There has been much debate as towhether SPFs higher than 15 “really do anything,” but I have re-cently changed my recommendation from an SPF 15 to an SPF30 for baseline protection when you are going to be outdoors forextended periods of time. An SPF 15 blocks out 92 percent ofthe sun’s rays. An SPF 30 blocks out 96 percent, and an SPF 45or higher blocks out 97 percent. But it is doubtful that SPF 45is really more effective than SPF 30. SPF 30, however, offers sig-nificantly more protection than SPF 15. While a 4 percent in-crease in protection may not seem like a lot, to your body it is,and the difference between an SPF 15 and SPF 30 is huge. Thehuman body is so highly fine-tuned that even the slightest vari-ation can help or harm it. Think of it this way: If a 140-poundwoman loses 4 percent of her body weight, she will lose almost 6pounds. In all likelihood the absence of those 6 extra poundswill make a difference in the way her clothes fit and probably inhow she feels.

I recommend daily use of the higher SPFs and frequentreapplication if avoiding the sun isn’t possible—though it is ad-visable. It is doubly important for people getting laser treatmentsand peels, and/or using bleaching products, Retin-A or Renova,or Accutane. All of these therapies make your skin more suscep-tible to sun damage, as do other medications, including certain


antibiotics and birth-control pills. Always ask your physicianabout this whenever you are prescribed a new medication.

3. Pick Your Perfect Formulation

Many of my patients don’t use sun protection because it hasmade them break out in the past. If you have oily and/or blemish-prone skin, go with an oil-free version to prevent your sunblockfrom exacerbating your condition. In addition, all skin types arebetter served by using a formulation geared specifically to theface rather than the one you use on your body; those formulatedfor the face are less greasy and less irritating.

4. Love It

Sunscreen only helps if you put it on. So find one with a texture,finish, and scent that you really like. This way, you’ll have ab-solutely no problem adding it to your daily regimen and reap-plying it as needed.

5. Time It Right

It’s important to apply chemical sunscreens (for example, oneswhich contain octyl methoxycinamate, octocylene, or avoben-zene) at least 30 minutes prior to sun exposure so these ingredi-ents can react with skin. These types of products absorb the sun’senergy, diverting it away from us. Physical sunblocks, such as ti-tanium dioxide or zinc oxide, work immediately; they literallyform a protective shield over our skin.

6. Be Generous

A classic error in sunscreen application (for even the most die-hard user) is not using enough. To be truly protected, we need touse a lot of sunscreen—about two to four ounces to cover your

34 L E V E L O N E

face and body, depending on your size. We also need to reapplyit every three to four hours and immediately after swimming orheavily perspiring (even if you are using a waterproof variety).Reapplication is also key to protecting skin from sun damage.

7. Don’t Forget Often Overlooked Places

To fully shield your forehead, it is important to work sunscreenat least 1/2 inch into the hairline rather than applying it acrossyour forehead in the side-to-side motion most people use. Twoother often neglected areas are the ears and the scalp. Both re-gions are endowed with very little protective pigment and caneasily become burned and develop skin cancer. Protecting yourlips is equally important.

8. Resist the Temptation to “Get as Tan as You Used To”

Many of my patients often say somewhat wistfully to me thatthey just can’t achieve that perfect shade of golden brown thatthey used to during their childhood and teens. There is nothingwrong with their vacation or suntanning regimen. Failing to gettan actually means your skin has “burned out” its own natural sunprotection, melanin. Repeated sun exposure and burning can dam-age the skin’s melanocytes, the cells that produce melanin or pig-ment, so the body may no longer be able to produce enoughmelanin to let you tan or tan as deeply as you used to. Somepeople also develop white spots on certain areas, which meansthat the melanocytes there have literally died because of an over-dose of sun exposure. If you’ve experienced either or both ofthese conditions, it means your body requires extra sun protec-tion—not additional hours of sunbathing.


9. Rethink Pink

A burn, unfortunately, isn’t the only sign of damage. Turningpink isn’t so great for you either. Pinkness is actually the sign of alittle burn. Skin that is chronically pinkened by the sun may alsobe undergoing a mutation to its DNA, which is associated with alltypes of skin cancers. Areas that stay pink permanently meanthat they have lost many of their melanocytes. These regions re-quire either more frequent sunscreen application or a higher SPFthan the one you are using everywhere else. The nose is more vul-nerable to becoming permanently pink than other parts of theface because it is the most exposed to the ultraviolet rays. For thisreason, it is the most common area for skin cancers. The chest isanother especially susceptible area. If any part of your face orbody turns the slightest bit pink, it’s best to apply a higher SPFthere, even if it means using two different sunscreens.

10. Beat the Heat

During the hottest hours of the day—from roughly 10 A.M. to3:00 P.M.—it’s a good idea to seek out some shade. The reason?The sun’s heat, not just its ultraviolet rays, decomposes the skin’svital proteins. Think of a steak left in the broiler. Even when youturn off the flame the meat continues to cook and shrivel up. Itmay have started out as rare but now, all of a sudden, it’s welldone.

4 . F I G H T F R E E R A D I C A L S :

L O A D I N G U P O N A N T I O X I D A N T S

As crucial as wearing sunscreen on a daily basis is to the healthand appearance of our skin, studies have shown that many prod-ucts may not be 100 percent effective in safeguarding us from sun

damage. Some ultraviolet rays can still penetrate skin and sparkthe formation of dartlike free radicals.

Our skin, ingenious organ that it is, contains enzymes andnatural antioxidants that help neutralize and protect it against freeradicals. Antioxidants are substances that prevent free radicals fromcausing oxidative damage, which is what leads to the wearing awayof collagen and elastin. If free radicals are like little darts pokingholes in our collagen and elastin, then antioxidants are the decoytargets that prevent them from hitting their mark.

As we age, our bodies no longer create these antioxidants andenzymes in the quantities we need to fend off these sneak free-radical attacks. Their production starts to slow down even as earlyas our twenties. But modern science has put us at a tremendousadvantage by discovering naturally occurring ingredients thatwhen ingested and/or applied topically help disarm free radicalsthe moment they form, and even prevent them from forming inthe first place.

So far, antioxidant vitamins C and E have proven to beamong the best free-radical scavengers. There is increasing med-ical evidence that they reduce the incidence of a number of seri-ous diseases, plus diminish and even reverse the signs of aging.There have also been studies with extremely positive findingsabout lycopene, which is found in tomatoes, watermelon, and redgrapes; green tea extract; white tea extract; beta-carotene, a pro-vitamin A, found in carrots and dark leafy greens; bioflavanoidsfound in blueberries and raspberries; anthocyanins, also found inred grapes; and P. emblica, extracts from the fruit, bark, and/orleaves from the Phyllanthus emblica tree.

Incorporating these nutrients into your diet and as ingredi-ents in your skin regimen can yield many health and beautybenefits. M.D. Skincare’s Antioxidant Face-Firming Complexcontains a cocktail of all these antioxidants, which I believe

36 L E V E L O N E

is more effective than formulas containing only one or two an-tioxidants. (See chapter 8 for more information on thesenutrients.)

As with exfoliating acids, I recommend using products thatincorporate as many different kinds of antioxidants as possible.New research has indicated that there are at least two differentkinds of free radicals—those triggered by the body (metabolic)and those sparked by the sun and other environmental assailants.Furthermore, some antioxidants work better in different portionsof the skin because some are lipid soluble while others are watersoluble. So far, studies have shown that lycopene is excellent atfending off environmental free radicals. Vitamin E is strong indisabling the metabolic variety. Vitamin C seems to combat both.Meanwhile, promising studies are now showing that green andwhite tea extracts not only can fight both types of free radicals butthat they also repair DNA. Damaged DNA increases aging, re-duces our defenses against free radicals, diminishes our cells’ re-generative ability, and can even result in skin cancer.

5 . B O O S T C O L L A G E N A N D E L A S T I N

P R O D U C T I O N : T H E A A N D C V I T A M I N S

C O N N E C T I O N

When our skin processes are functioning optimally, they are in astate of what is called dynamic equilibrium—meaning our capa-bility to regenerate collagen and elastin keeps pace with their nat-ural degeneration. As time goes by, we have less and less of anability to maintain dynamic equilibrium, so these proteins beginto degenerate faster than our body can repair them. In addition,not to be a harbinger of bad news, but credible scientific researchshows that at age thirty, collagen and elastin production starts todecline in quantity and quality. There are many proven ingredi-


ents with exciting research behind them, however, that can helpus forestall and even reverse this process.

Vitamin C, so far, has proven to be one of the strongest cata-lysts of collagen growth especially when it’s applied topically. Us-ing products that incorporate this nutrient, as well as eating foodsthat contain it, can significantly improve that quality and quan-tity of the collagen we produce, which will make skin firmer,more radiant, and healthier-looking today, and help keep it look-ing that way tomorrow. And although taking oral vitamin C isimportant and healthy (see chapter 8), applying it topically is themost potent way to get its antiaging benefit for your skin. If youdo the math, one would need to eat more than one hundred250mg vitamin C pills (which is highly toxic!) to get the sameamount of vitamin C to your skin provided by simply applying a5 percent vitamin C cream.

Retinoids, derivatives of vitamin A, have also proven to be im-portant parts of the antiaging arsenal. Studies have shown thatthey stimulate the production of new skin cells and inhibit thebody’s natural enzymes that break down collagen. At Level One,using retinol, the nonprescription strength variety, should do thetrick. Prescription-strength tretinoin, which is the key ingredientin Retin-A and Renova, is indeed a more potent wrinkle fighter,but it can also be irritating and increase your skin’s sensitivity tothe sun. Incorporating both vitamin C and retinol into a dailyskin-care regimen will help to tackle erosion of both collagen andelastin safely and effectively.

There are other antioxidants and collagen builders that havesome positive data behind them, but the findings are less clear. Forexample, copper peptides, proteins merged with copper and ironthat occur naturally in skin seem to play a role in collagen and elastinformation. Some studies have shown that when applied topically,copper peptides can significantly reduce the signs of sun damage

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and improve faint to moderate lines and wrinkles. Coenzyme Q-10 (a.k.a. ubiquinone) might also be another collagen builder.This compound is made by our bodies and used by our cells toproduce the energy they need to grow and be healthy. Also an an-tioxidant with actions very similar to those of vitamin E, coen-zyme Q-10 has been found in some studies to be an excellentdefender against free radicals and when used regularly, over time,it may help ease lines and wrinkles by building collagen. In addi-tion, some studies have suggested that kinetin, a naturally occur-ring growth hormone found in plants and animals, has antioxidantproperties and may play a role in stimulating collagen synthesis.Peptides are among the newest collagen-boosting ingredients usedin products such as Strivectin, which incorporates pentatpepide–3.All of these ingredients may or may not prove to be excellent agebeaters, and more research is needed to establish their benefits.Stay tuned.

6 . P A M P E R Y O U R U N D E R - E Y E A R E A : S T A V I N G

O F F T H E V E R Y F I R S T S I G N S O F A G I N G

Most of my Level One patients kick off their antiaging regimenby starting to use a moisturizing under-eye cream or gel. Typi-cally, that is the first part of the face to look a little worse for wear.This is because the skin there is especially thin and so more proneto the lines caused by wear and tear and sun damage.

While a moisturizing eye cream will keep the area lookingplump and dewy, using one that also contains antioxidants, sun-screen, vitamin C, and retinol is an even better way to go. Wear-ing a product with sunscreen and antioxidants during the day willhelp to prevent sun damage and free-radical formation. Using acream or gel with vitamin C and retinol at night will help tojump-start collagen content. I recommend using products specif-


ically created for the under-eye region, rather than ones for theface, because they have been formulated to be extra gentle on thisespecially sensitive area.

Reading and working in a well-lit room, wearing sunglasses out-side, and wearing the right corrective lenses for any vision problemswill all help to minimize the wear and tear we unwittingly cause tothe skin under and around our eyes every time we squint. Andwhile this may seem nitpicky, resisting the urge to rub itchy eyeswill also help to reduce the amount of stress this area is subjected to.

To Moisturize or Not toMoisturize?

While it has been marketed as the cornerstone of an antiagingskin-care regimen for at least a century, moisturizers actually won’tturn back the clock; they are merely an effective way to alleviatedry skin. So if you have Level One skin and it isn’t dry, you don’tneed a moisturizer. (PLEASE NOTE: If your skin is Level Two orhigher, turn to chapter 4 for your moisturizing specifics.) Instead,you can find active antiaging ingredients, such as vitamin C andalpha hydroxy acids, in pads, gels, and serums that won’t add un-necessary oil to skin. But if even after switching to a mildercleanser your skin is still dry and flaky, it’s a sign that it needs ad-ditional moisture.

To help prevent the clogged pores and blemishes to whichLevel One skin is prone, I recommend starting out by using amoisturizer in the form of a lotion, which is the lightest weightand so the least likely to cause breakouts. If your skin still needsmore moisture, move up to a cream version, which has more oil

40 L E V E L O N E

in it. The next step would be to switch to formulations geared to“extra dry,” followed by those for “severely dry” skin if necessary.

You might find it necessary to switch moisturizers or adjusttheir frequency from time to time, such as with the change of sea-sons, or depending on what other products you are using.

First to Last:The Right Order for Your Basics

One of the keys to maximizing the benefits of any product in yourdaily skin-care regimen is to apply products with a thinner con-sistency before the thicker more creamy ones, no matter what theiractive ingredients are. Products with heavy consistencies can blocklighter-weight ones from penetrating the skin and doing their job.Here is a sample application order:

1. Liquids, such as antiacne or light peel pads for

exfoliating and collagen building, or any kind of

toner.

2. Serums or gels, which are more viscous than a

liquid but less so than a lotion and can do every-

thing from moisturize to deliver vitamin C or

offer sun protection.

3. Lotions, which are milky, slightly thicker liquids,

and can include moisturizers, moisturizers with

sunscreens, and moisturizers with antioxidants or

exfoliating acids.


4. Creams, which can do all of the above but are

thicker, richer substances that won’t spill out of a

jar if it’s turned over.

5. Ointments, generally petrolatum-based solids

that come in a tube and squeeze out very slowly,

such as Vaseline.

The exception to this rule of thumb is that any form of sunprotection, be it in a moisturizer or not, must be applied beforeany other product (except a liquid). Its defensive ingredients needto cling directly to skin in order to be most effective.

Apply products to cool, dry skin to ensure their effectiveness aswell as decrease the chances of irritation. Water, even microscopicdroplets, also can prevent active ingredients from penetrating. Aftertoweling dry, it’s a good idea to wait an extra minute or so to makesure that any remaining water has totally evaporated. But here isanother tricky exception: If you are just putting on a moisturizerwithout any other active ingredient, it’s best to apply it immediatelyafter toweling off to seal in additional moisture.

It’s also wise to let any redness fade after showering or cleans-ing before using any treatment product. When skin is red, all ofits vital functions are struggling to help it return to a calmer state,so any active ingredient might be more than it can handle at thatgiven moment. When skin is in this recover mode, productsthat it otherwise might have been able to tolerate can prolong theredness and make it appear irritated.

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Monitoring Your ResultsUnfortunately, there is no way to know in advance how well aproduct will work. Companies aren’t required to list the percent-ages or strengths of main active ingredients on labels of nonpre-


Food for ThoughtFacials and Masks: Are They Antiaging?

Facials: Many of my Level One patients start to get facials regu-larly at this time in their lives thinking that they are a way topreserve a youthful complexion. But there is no data supportingthe antiaging claims often made for facials. Facials for the mostpart pamper, moisturize, deep cleanse, make skin more beautiful,and give the face a temporarily more refreshed and rejuvenatedappearance. Some spas, however, recently have incorporatedbona fide antiaging treatments into their menus, including mul-tiacid peels and facials incorporating vitamin C. These treat-ments can help rev up our skin’s collagen-boosting machinery.Peels are especially effective when coupled with facials, which bydesign exfoliate dead skin cells so any active ingredient can pen-etrate the skin better.

Masks: Similar to facials, masks are not fountains of youth, butthey can provide an intensive way to help remedy a host of skinproblems, such as dullness through exfoliation; dryness throughconcentrated moisturization; blemishes through deep cleansingand drying up excess oil; eye puffiness through anti-inflammatoryingredients, or large pores through sloughing out the debris thatstretches them out in the first place. When used as directed theycomplement but do not replace a solid antiaging daily regimen.

scription products, unless they are classified as a drug. And oftena product’s efficacy is based on a combination of ingredientsrather than each one’s concentration. A product or regimen maynot make a huge visible difference now to Level One skin becauseit is used more to prevent future damage and optimize the skin’svital functions rather than to turn back the clock. But good skincare today makes all the difference in how we will look tomorrow.

Still, taking these largely preventative measures should im-prove the overall condition and appearance of your skin. It shouldbecome smoother, more radiant, and evenly toned. Here is a keyrule of thumb: If you don’t notice some kind of positive changeafter four to six weeks of using a product, try something else. Onthe other hand, stop using a product immediately if it causes pro-longed stinging, burning, itching, blemishes, or redness. It’s agiven that it won’t be beneficial to you in any way.

Specialized Treatment for Problem Areas

We all have regions of predictive vulnerability on our faces thatmight require some extra attention, and they may age faster thanthe rest of our faces. Our genetics, the way we look when we aretired versus well rested, areas of crinkling, and the lines or creasesthat pop up when we make a facial expression, can all indicatethese problem areas.

In addition, our relatives’ skin problems can also help us topinpoint certain skin conditions that we might be predisposed to.Some of the most common causes of concern for Level Ones arenot age related. They include breakouts that follow them into

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adulthood; rosacea, which sometimes occurs in the twenties; der-matitis; under-eye circles and puffiness. If after three months oftaking the measures described below, you still want further im-provements, you might want to consider the slightly more aggres-sive treatments outlined in chapter 4.

C L E A R I N G U P A C N E

It’s not fair but often times we finally manage to emerge from anacne-ridden adolescence only to find that blemishes follow us intoadulthood. Adult breakouts are particularly common to womenin their thirties, mostly due to hormonal fluctuations, but theystill can occur at any time. But while it may look the same, adultacne needs to be handled differently from the teenage variety inorder to prevent the dryness and irritation that prompts skin toproduce even more potentially pore-clogging sebum.

To treat acne most effectively yet gently, start out by usingover-the-counter antiacne remedies that contain either exfoliat-ing, pore-clearing salicylic acid or bacteria-banishing benzoyl per-oxide. If neither works well enough independently, try usingthem both together. If you still aren’t pleased with the results aftera month, it’s probably time to see a dermatologist who will pre-scribe the appropriate course of action for you. If you have a cyst(a painful infected nodule), it’s wise to see a dermatologist as soonas possible since they generally don’t respond to over the countertreatments and only get worse if left unchecked.

Prescription remedies for acne may include birth control pills(some are FDA approved to work on acne by controlling hor-monal fluctuations); antibiotics to kill bacteria, such as tetracy-cline, doxycycline, and minocycline; topical tretinoins (retinoicacids), such as Retin-A and Differen Gel, which will help preventblockages in the oil glands, or the antiacne drug Accutane, an oral


retinoid. Here are a few tips to help you maximize any antiacneregimen, whether it is prescription or over the counter.

� Plan ahead: Pimples are extremely sneaky. The

ones that appear next week are actually per-

colating today. So if you tend to get blemishes all

over your face rather than in specific spots,

unless directed otherwise by your doctor, stop

them before they start by applying a thin layer of

antiacne medication all over your face, not just

on existing blemishes.

� Look for patterns: While breakouts may seem

totally random, they actually often are “sched-

uled.” For example, they may routinely get worse

the week before your period. If this is the case,

treating skin around this time can greatly reduce

their severity. Stress is also a notorious acne

aggravator. So if you know you are about to

enter a stressful period, start applying your

product before you get there.

� Change your regimen as needed: Since nearly all

acne treatments can dry out skin, switch to a

milder cleanser and/or start using oil-free mois-

turizer. Taking these measures is more beneficial

for acne-prone skin than having to cut back on

the strength or frequency of antiacne medica-

tions because of dryness.

It is understandably tempting to pop a pimple in an attemptto minimize its appearance. But this is one temptation I urge youto try your hardest to resist. When a dermatologist drains a pim-

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ple, the doctor applies downward pressure perpendicularly to theskin’s surface. When people try to pop their own pimples, theyusually squeeze them from the sides, a technique that inevitablybackfires. The reason? Squeezing a compressible substance fromthe sides causes as much infection to go down deeper into thepore as is released outward. This may permanently enlarge poresand worsen infections. Meanwhile the pressure from nails cancause broken blood vessels and permanent scarring. If the temp-tation is just too great, try washing your face with a clean wash-cloth. If the pimple is ready to “pop,” this is all the pressure itshould need to drain. If it stubbornly refuses to budge, it’s reallybetter in the long run to just let it run its course.

C A L M I N G R O S A C E A

At Level One, sometimes what appears to be acne is actuallyrosacea. Though it tends to put in its first appearance in the thir-ties and forties, rosacea can develop at any time in varying degreesof severity. People with fair skin are more prone, and it does runin families. Rosacea’s exact cause has been an endless source of de-bate in the medical community, but it is known to have both abacterial and an inflammatory component. Its symptoms includediffuse redness (flushing), broken capillaries, and inflamed bumpsor pimples, which is why it is often confused with acne. But con-ventional blemish remedies, such as benzoyl peroxide and RetinA, generally exacerbate rosacea because they provoke more in-flammation, though it is possible to have both conditions simul-taneously, in which case consulting a doctor as to your appropriatecourse of treatment is your best bet.

It is possible to control a mild case simply by limiting caffeine,alcohol (especially red wine), spicy food, and exposure to extreme


temperatures. There are also many over-the-counter remedies,which are designed to reduce redness and soothe inflammation.Maintain an extremely gentle cleansing regimen and avoid alcohol-based products to help reduce the frequency and severity of flare-ups.

Angie,* twenty-four, had rosacea but was reluctant to admit itbecause she thought that it “only happened to old people.” Beforeshe saw me, she had had one minor outbreak and her doctor hadgiven her a prescription for medication, which she never used. Afew months later, she had a full-blown attack that she started treat-ing with antiacne remedies, which only made things worse. Afterspeaking in depth, we realized that her rosacea was entirely dietaryrelated. She only had flare-ups after she ate spicy foods, which shedid most of the time. Specifically, she would spice up anything sheate—even her morning eggs—and had a real penchant for Indianand Mexican cuisine. She has since eliminated spicy foods fromher diet and hasn’t had a problem since. But eating just one mealor even a bite of spicy food can trigger an outbreak. Ellen, thirty-three, actually had a bad attack from eating just one chip withsalsa.

But if taking the above steps aren’t enough to prevent andclear up rosacea eruptions, you might want to consider incorpo-rating the more aggressive preventative and curative measuresoutlined in chapter 4 into your regimen. And if one or more ofthe following symptoms accompanies your breakouts, I suggestseeing your doctor: excessive facial or body hair growth; irregularperiods; unexplained weight gain or loss; and/or excessive hairloss. These symptoms could indicate thyroid or other hormonalimbalances, such as polycystic ovary disease, which if left unchecked,can promote greater health problems and compromise fertility.Blood tests may show testosterone, prolactin, DHEA, thyroid, and

48 L E V E L O N E

*The name has been changed.

other hormones. These symptoms may also occur as the result ofthe acute hormonal fluctuations associated with pregnancy, start-ing or stopping birth control pills, or nursing. When in doubt, seeyour doctor.

S O O T H I N G S E B O R R H E I C D E R M A T I T I S

Because it has many of the same symptoms as severely dry skin—itching, redness, flaking, and scaling—seborrheic dermatitis canbe difficult to self-diagnose. But it is actually an inflammatoryrash, not a condition caused by lack of moisture. Unfortunately,treating it as though it were dry skin with intense moisturizationwon’t help it, and exfoliation only aggravates the rash. One way todistinguish seborrheic dermatitis from ordinary dryness is that itis usually localized, in particular around the sides of the nose and/or eyebrows. If this is the case, try treating the rash as it crops upwith an over-the-counter 1 percent hydrocortisone cream. If thedry flakes persist, see a dermatologist to confirm your diagnosisand for a stronger or more targeted treatment.

F A D I N G D A R K C I R C L E S

For the most part, dark under-eye circles in Level One are the re-sult of lifestyle habits such as smoking, drinking too much caf-feine, overindulging in alcohol, and not sleeping enough, ratherthan the thinning of the skin that occurs with aging. Nicotine, al-cohol, and caffeine cause the capillaries to leak iron and bloodcells into the under-eye area, giving it a dark appearance. In addi-tion, lack of sleep, or extreme stress can put your body into flightor fight mode, which means your brain, like other vital organs,leaches every single molecule of oxygen it can from the blood, soa darker more deoxygenated blood flows through our veins to the


other areas of the body. This dark blood is most visible in thetransparent skin under our eyes and is what causes the appearanceof those discolored rings.

In addition to maintaining a healthy lifestyle, keeping any al-lergies or sinus conditions in check can also help to reduce darkcircles. Eye creams with vitamin K can heal the broken capillariesto prevent them from leaking blood into the under-eye region.Other helpful ingredients include retinoids and vitamin C (ascor-bic acid), both of which will help to thicken the skin so anydarkness there becomes less visible. I specifically took this mul-tipronged approach when I formulated M.D. Skincare Lift &Lighten Cream.

Sometimes dark circles are the result of hyperpigmentation,areas of the skin that are permanently darker than the rest of theface due to sun damage, hormonal fluctuations, or genetics.Tanya, twenty-seven, for example, seemed to develop superdarkcircles overnight, something not uncommon for people with olivecomplexions. She slept well and maintained a healthy lifestyle buteven so, those rings got darker and darker. That phenomenon letus rule out leaky capillaries and darkened blood flow as the cause.We had her start using an over-the-counter eye cream, which con-tained skin thickening ascorbic acid plus kojic acid, another light-ening agent. After three months of twice daily usage, the circleswere significantly lighter. She even cut down the amount of con-cealer she used to apply by about a third.

D E F L A T I N G P U F F Y U N D E R - E Y E S

Pouching out of the under-eye skin can have several causes. Themost common is inheriting thick or unevenly distributed fat padsin that region. This thickness can be compounded by water re-tention due to diet, sleeping habits, alcohol, and hormonal fluc-

50 L E V E L O N E

tuations (bags are often bigger right before your period when thebody tends to retain more water). They can also be due to aller-gies and sinus conditions. When the nose or sinuses are inflamedand congested, fluid accumulates under the eyes in the fat pads.

If you have a tendency to become puffy, reduce salt intake andminimize alcohol consumption, since both salt and alcohol canmake us retain excess water. Taking any allergy or sinus medica-tion daily as directed—not just with an attack—can prevent theswelling of the nasal passages and sinuses that also can inflate thearea. Sleeping on our backs as opposed to our sides or stomach,and elevating the head of the bed are other good ways to help pre-vent fluids from collecting and stretching out under-eye skin. An-other excellent way to prevent and reduce under-eye puffiness isto do some form of cardiovascular exercise regularly, since revvingup the circulatory system and sweating helps us to release excesswater. In the past, many doctors advocated surgically removingthe under-eye fat pads on younger women who were bothered bybags. However, if performed too early or if too much fat is removed,the under eye can look eerily hollow as we age. In addition, under-eye puffs caused by sinus and nasal congestion won’t be fully flat-tened even if the fat pads are taken out.

One new way of thinking is to treat under-eye pouches withproducts that temporarily tighten the skin and liberate trappedfluid. In my experience, under-eye gels with caffeine and cucum-ber extract are the ones that really work. In addition, preparationswith green tea extract can soothe redness and inflammation.

While many articles on the subject have advocated puttingthese products in the fridge to impart them with even more anti-swelling benefits, I don’t find this to be the case. It may make themfeel more soothing and cooling to inflamed skin but our body tem-perature warms them up in seconds, thus eliminating their powersof deflation. The same goes for those ubiquitous cold cucumber


slices seen fairly frequently on young starlets getting Hollywood-style facials on the big screen. While they certainly can’t hurt, theyaren’t quite cold enough and don’t contain enough concentratedcucumber extract to make a real difference, though I suspect put-ting new slices on as soon as the old ones heat up could make themsomewhat effective. Natural remedies that seem to work better in-clude ice packs, which decrease swelling and inflammation, andfrozen green or white tea bags (their tannins are a natural anti-inflammatory).

In addition, certain foods, like celery, cucumber, watermelon,parsley, and parsnip have a natural diuretic effect, which also canhelp reduce puffiness. However, prescription or over-the-counterdiuretics should never be taken without the guidance of a physi-cian. And one more advisory: There’s that old chestnut aboutPreparation H being the antipuff product of choice for models atphoto shoots and fashion shows. I don’t know how that one gotstarted, but that ointment is meant for only one area of the bodyand that isn’t under our eyes.

L I G H T E N I N G S U N S P O T S A N D O T H E R

D I S C O L O R A T I O N S

Brown spots and freckles are actually little growths caused by cu-mulative sun exposure. These round sunspots are darker than therest of our faces because they are filled with excess melanin pig-ment, our skin’s defensive reaction to the sun. If the darkness is lessfreckly and more patchy and diffuse it could be melasma. Melasmausually includes dark streaks on the upper lip, forehead, or aroundthe eyes. In addition to sun exposure, female hormones worsenmelasma, especially during pregnancy (called pregnancy mask) orwhen taking oral contraceptives. However just being in your repro-ductive years is a risk factor for developing it.

52 L E V E L O N E

The good news is that we can greatly reduce the severity of andrisk for developing either condition by wearing a broad-spectrumsunblock with at least an SPF 15, sunglasses, and a wide-brimmedhat on summer days. At this level, over-the-counter bleaching—also called lightening or whitening—products with active ingredi-ents such as ascorbic acid, combined with kojic acid or hydro-quinone can do an excellent job of lightening both sunspots andmelasma. I recommend using products that contain several differentactive ingredients, since they are generally more effective and lessirritating.

All bleaching products can be harsh even when used as di-rected. They also cause hypersensitivity to the sun. It is an oddparadox that the key remedy for hyperpigmented skin can worsenthe problem. Both irritation and photosensitivity actually can makedark spots darker and increase our chances of getting new ones. Ifskin becomes red and irritated from any bleaching product, cutback on its frequency of use, say from every night to every othernight. Be especially diligent about wearing sunscreen and eventrade up to an SPF 30 to help the lightening agents effectively dotheir job without exacerbating the problem.

For the best, least skin-irritating results, apply a thin amountonly to dark areas at least one hour before bedtime. This will let itfully absorb into the skin so it won’t slide into your eyes when youpress your face into the pillow. When applying it, avoid getting itinto your eyes since it will sting. As effective as some bleachingagents can be, especially stubborn sunspots may require a few ses-sions of laser therapy to eliminate them. For details, turn to chapter4. Melasma, however, is exacerbated by laser treatments and soshould only be treated with bleaching products.


H A N D L I N G B R O K E N C A P I L L A R I E S

Those little red squiggles are actually misnamed—they are not somuch broken capillaries, as they are extra capillaries. Our skinforms these additional blood vessels when our bodies and/or skinhave been subjected to some kind of trauma so that the blood,nutrients, and oxygen it needs can be carried there to heal thedamage. They are also a component of rosacea, but can be the resultof any facial trauma, such as squeezing a blemish overzealously.

Extreme temperatures can also cause broken capillaries. Pro-longed exposure to the excessive heat of fireplaces, steam rooms,saunas, and Jacuzzis can cause our body to create extra blood ves-sels to increase blood flow to help cool us off. Excessive cold, onthe other hand, prompts our body to conserve heat internally byconstricting the blood vessels on the skin’s surface. Skin then be-comes shortchanged of the nutrients, blood flow, and oxygen itneeds to function optimally. In response to this stress, our skinproduces more vessels in an attempt to supply it with what it islacking. Limiting caffeine, alcohol, and spicy foods also may helpprevent capillary formation—especially if you are genetically pre-disposed to rosacea. At this time, no topical product or ingredienthas been proven effective at shrinking or eliminating these tinyred lines. The only way to get the job done is with a few sessionsof nonablative laser treatments. See chapter 4 for more details.

S T A V I N G O F F L I N E S , W R I N K L E S , A N D S A G G I N G

While lines, wrinkles, and sagging are all caused by the break-down of collagen and elastin, each problem is unique in why andwhen it appears. For Level One skin, you can prevent and treat allthree in the same way—mostly with the collagen-building and

54 L E V E L O N E

skin-protecting measures previously described. As we age, though,each problem might require slightly different tactics.

Lines are generally the result of wear and tear to the areas ofour face that are involved in its movement—its natural grooves orseams, so to speak. The best examples are the lines around oureyes and in between our brows. After years of squinting or scowl-ing, be it in concentration, perplexity, or anger, the collagen andelastin eventually break down, resulting in creases. Wrinkles,however, occur in the areas of the face that are stationary, such asthe cheeks. There’s really no reason for their existence other thanenvironmental damage and the passage of time. Sagging, on theother hand, is mostly the result of genetics. It all depends on thethickness of our skin as well as the formation of its structural pro-teins and connective tissue.

Believe it or not, retraining ourselves not to make some verybasic facial expressions, such as scowling, can make all the differ-ence in minimizing the appearance of lines. Whenever we feeltense or angry, if we consciously take a moment to take a few deepbreaths, it will not only benefit our psyche and ability to make aclear decision, but also our skin, since it will force us to relax ourfacial muscles. Taking B-complex vitamins or so-called stress tabshave also been shown to ease tension.

To help prevent sagging and the appearance of deep creases inour nasolabial folds (the deep lines that run alongside the nose tothe mouth), it is important to keep our weight stable and avoiddramatic weight loss past forty, which can tax our skin’s elasticityand disproportionately deepen our nasolabial folds. Restrict ex-posure to the extreme collagen- and elastin-decomposing heat ofsaunas, steam rooms, and Jacuzzis as well as limit the amount ofhigh impact exercise. While such exercise may benefit our hearts, itcan cause the fat pads to slide south and collagen and elastin to break


56 L E V E L O N E

down. Quit smoking, so the face no longer receives secondhandsmoke, which produces free radicals—another major offensive play.

The best news of all? Putting on a little weight can definitelyplump up a sagging and/or drawn-looking face as well as push outlines and wrinkles.

At Level One, the important thing to remember (but not gethung up on) is that at this phase in your skin’s life cycle, beauty isreally only skin deep; deep down below its surface, it is starting toage. But the good news is that you can both forestall and reversethe mechanisms that are already at play. Prevention here is clearlydefined: You should focus on collagen production and defendyourself from further damage from the sun and free radicals.

4Level Twoy

A C T I V E R E P A I R A N D P R O T E C T I O N

I f you scored Level Two (a range of 35–46), now is your greatestopportunity to take charge of your skin and postpone the signsof aging. Your skin is at a very dynamic phase of its life cycle

right now and still maintains many of its defense and regenerativeabilities, so your face will respond all the more favorably to anycourse of action your choose. You also have an enormous oppor-tunity to take good, solid preventative measures that will, withoutquestion, prolong your skin’s youthful appearance. In terms ofage, my Level Two patients are generally in their early thirties toforties and are starting to have some concerns about theirappearance. It could be sheet marks that linger longer thanthey used to, sunspots that don’t fade after the summer, fine linesaround the eyes, and/or a furrow between the brows. Perhapsthere’s a crinkling effect in the skin when you pinch it and insome places when you don’t, slight sagging, visible red blood ves-sels (broken capillaries), more pronounced acne or chicken pox

scars, and/or enlarged pores. This is because the aging that hadbeen going on previously only under your skin has now started tosurface.

As previously discussed, the level of your skin is not just agedependent. If you are generally happy with the way you look,Level Two measures will almost certainly give you all the im-provements you desire whether you are in your thirties, forties,fifties, sixties, or seventies. These strategies also encompass goodbasic skin-care habits that women of all ages can combine withthe measures listed in the previous chapter (Level One) and inchapter 8 to use as the building blocks of their regimen.

The science of antiaging has made leaps and bounds over thelast decade and continues to discover better, faster, less invasive,and easier ways to turn back the clock and keep it there. The ad-vent of nonablative (no injury) lasers, light acid peels, hyaluronicacid–based fillers, and the refinement of Botox injections all pro-vide exciting and amazingly effective ways to keep your skin lookingits best with little or no recovery time and are nearly tailor-madeto your skin’s present condition. If these treatments are coupledwith solid daily skin-care habits and a healthy lifestyle, they willcontinue to give you stunning results as your skin matures.

The most important thing to remember at this level is not todo anything drastic or permanent. Procedures such as permanentfillers, surgical implants, or a face-lift, simply may not look goodover time as your face matures and changes shape. And becauseyou are, for the most part, happy with your appearance, a dra-matic change is not really what you are looking for right now—and maybe not ever.

For now, temporary is truly the only way to go. Start yourantiaging regimen off with the least aggressive at-home proceduresand over-the-counter products. Then you can gradually workyour way up the ladder in terms of aggressiveness to prescription

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products and in-office treatments, if need be. My other caveat,which rings true for all levels, is to resist the temptation to be thefirst kid on your block to try any new ingredient or procedure.There are enough antiaging treatments that have been proven bygood solid science to be safe and effective that you never need toput yourself at risk for something that hasn’t.

The BasicsWhile this chapter will offer slightly more aggressive alternativesto intensively treat specific areas of vulnerability, a sound dailyskin-care regimen is still the cornerstone of beautiful skin. All thehigh-tech ingredients and treatments in the world will never beable to achieve their full benefits if your skin isn’t in the best con-dition it can possibly be. Here are a few simple additions and ad-justments to the daily skin-care regimen discussed in chapter 3.Your basic routine will still involve cleansing, exfoliating, buildingcollagen and elastin stores, and paying extra attention to your under-eye area, while defending your skin against the sun and free radi-cals. However, in this chapter, we will intensify your daily defensivemeasures while adding in some reparative ones. These small changeswill go far in helping you get and maintain sensational-lookingskin.

1 . J U S T A D D W A T E R : M O I S T U R I Z I N G

T W I C E A D A Y

It’s no secret that water plays an important part in our well-being.It comprises nearly two-thirds of our body weight and at least thatmuch of each of our vital organs as well as our muscles. Water is

A C T I V E R E P A I R A N D P R O T E C T I O N 59

also a key ingredient in radiant, healthy-looking skin and helps itto maintain a certain degree of plumpness—in this instance, avery good thing. When skin is plump, lines and wrinkles are lessapparent and enlarged pores look smaller.

Your skin is actually designed to draw in water and trap it there.This capability is due to sodium hyaluronate, a complex moleculefound naturally in the fluid between the skin cells, which canhold up to 100 times its own weight in water. Also known ashyaluronic acid, this virtual moisture magnet first attracts thenlocks water into skin. As we age, our skin’s overall water contentand its hyaluronic acid stores both decline. Menopause also re-duces skin water content due to reduced estrogen (see chapter 6).But bringing back some of what time takes away is simple enough—just use a moisturizer twice a day.

A moisturizer works in two phases: It first delivers water tothe skin and then seals it in with an emollient ingredient, such asoil. Even if you have oily skin, you can still benefit from addingwater to your skin (also called hydrating) with a moisturizer be-cause oil (your skin’s lipids) and water actually serve two com-pletely different functions. Water keeps the skin supple, whilelipids are the sealants that trap it there. If you have oily skin, us-ing an oil-free moisturizer will still increase skin plumpness andvibrancy due to its water content, but won’t clog pores or causeblemishes because it lacks oil. Products that contain hyaluronicacid are particularly effective for oily complexions and, actually, agreat choice for all skin types. When applied topically, hyaluronicacid works very much the same way as it does internally—it at-tracts water and then traps it inside the skin so that no extrasealant (emollient) is necessary.

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2 . B O L S T E R Y O U R N A T U R A L D E F E N S E S :

T H E B E N E F I T S O F R E T I N O L A N D G E N I S T E I N

T O P R O T E C T A N D B U I L D C O L L A G E N

Antioxidants such as green tea extract, vitamins C and E and ly-copene continue to play an important part in your collagen-protecting, free radical-destroying routine. But free radicals aren’tthe only collagen chompers. Your skin actually contains naturallyoccurring enzymes that erode it, as well. As we mature, these en-zymes become stronger than the mechanisms in our skin thatcombat them. Retinol has been found to combat these destructiveforces, giving us just one more reason to include it in our dailyskin-care regimens. But a newer ingredient with promising re-search behind it may prove to be as, if not even more, effective.Genistein, a component of soy extract, isolated by Dr. Genistein inSwitzerland, has been shown to block and diminish these collagen-destroying enzymes considerably. The best part? It is completelynonirritating and so works beautifully with all other antiaging in-gredients. Still, genistein, a nonprescription ingredient, should beconsidered an addition to your regimen rather than a retinol re-placement. The more ways you can defend yourself against colla-gen breakdown, the better.

3 . R E V U P C E L L R E N E W A L :

E X F O L I A T E W I T H L I G H T P E E L S

Another surefire way to keep skin glowing and smooth is to exfo-liate daily to prevent the buildup of dulling dead skin cells andother debris. While your cell turnover starts to decline at thirty, itcontinues to slow down with the years. Consider exfoliation thekey to keeping this function alive and kicking. In addition to giv-ing you a smoother and more radiant complexion, consistently


increasing cell turnover may have the added benefit of stimulatingcollagen production. Repeated exfoliation and the reduction indead skin cells that results are believed to rev up the machinerythat helps renew the skin. Take men who shave (an excellentmeans of exfoliation), for example. The lower part of their face,the area that they most commonly shave, actually ages better thantheir upper half, which for the most part, has never seen a razor.

If you haven’t already embarked on the basic skin-sloughingsteps outlined in the preceding chapter, your skin would defi-nitely benefit from trying them now. If you have already incorpo-rated these steps and are happy with the results, don’t change athing. If you are finding that you need a little extra help, however,you can kick your exfoliating efforts up a notch with light acid(also called superficial chemical) peels.

The word “peel” is actually a misnomer. In reality, a peel is atwo-step process with no actual peeling involved. The first step isto swab a mixture of exfoliating acids on skin to remove the deadcells and other skin-dulling debris. The second step is to apply aliquid base that neutralizes the acids and conditions the skin. Inaddition to stimulating collagen production, which will softenlines and wrinkles, firm skin, and even our skin tone, repetitivepeels can also help to reduce pore size, fade discolorations, im-prove rosacea, as well as to treat and prevent acne.

In peels, it is not only the exfoliating act of the acids that’s fir-ing up collagen formation, but the PH fluctuation the skin expe-riences as it goes from acidic to neutral. I’ve coined the termPhlux because it is such a powerful action. Phlux appears to be aneven bigger catalyst in cell turnover and creates an extra benefit toconventional exfoliation with a lotion or cream alone. The morepotent the ingredient that exfoliates and the more dramatic thePH fluctuation, the more revved up your skin becomes to replaceand renew the skin. As seductive as this concept may be—the

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deeper the peel, the more collagen you produce—don’t let it swayyou into automatically assuming a deep peel is your best course ofaction. While deep peels produce more collagen than light peels,this production is in direct response to the damage the peel in-flicts to your skin. Medium and deep peels are actually controlledinjuries to your skin and stimulate collagen synthesis in much thesame way that a deep cut or burn promotes scar tissue as part ofthe healing process. And while that damage does come with thebenefit of enhanced collagen production and so can smooth awaydeeper lines and darker sunspots, it also carries some risks, whichwe will discuss in Levels Three and Four (chapters 5 and 6).

But the good news is that when light peels are performed ona regular basis, they can have very similar benefits to deep ormedium peels without the potential side effects. I have consis-tently found that the cumulative results of repetitive light peelscan exceed those of medium peels and come close to those of deeppeels without any of the associated risks.

The safest and most effective light peels contain a variety ofacids so that each one can be used in lower and less irritating con-centrations. I developed the M.D. Skincare Alpha Beta Peel tenyears ago in response to the harsh glycolic acid peels that were cur-rently the rage in the dermatological community. (See “A Series ofAlpha Beta Peels” in the photo section.) I was frustrated because Ifound these procedures to be overly aggressive without achievingthe desired results. The Alpha Beta Peel is available in home, spa,and medical grades. All of the versions contain salicylic, malic,citric, lactic, and glycolic acids, as well as soothing green tea ex-tract, which also protects against free radicals, and retinol, whichfurther stimulates collagen synthesis, strengthens connective tis-sue and inhibits the enzymes in our skin that degrade collagen. Ihave recently incorporated genistein into them, as well.

Andrea, thirty-eight, is practically a poster child for light acid


peels and talks about them to anyone who’ll listen. She had alwayshad nice skin, the result of limited sun exposure when she was achild and good genetics. She came to me in her early thirties orig-inally for removal of a mole, which actually turned out to be pre-cancerous, but then started asking me how she could keep herskin looking good longer and maybe even make it a little better(she had a slight tendency toward rosacea and some enlargedpores on her nose). We started her on in-office peels once a month,using the daily at-home Alpha Beta Peel, and wearing sunscreenon a daily basis, plus topical vitamin C product at night. After justa few months on this regimen, she says perfect strangers were ask-ing her the brand name of her makeup when she wasn’t wearingany and that people are shocked when she tells them she’s beenmarried for twelve years because they generally assume she’saround twenty-eight.

Nancy, thirty-six, is also a huge Alpha Beta Peel fan. Eventhough she had been careful of the sun her whole life, when shehit her early thirties, her pores got bigger, she had diffuse crin-kling all over her face, and her skin just wasn’t as tight as it used tobe. She felt that all these things made her look older than she ac-tually was. Within months of doing monthly in-office peels andusing at-home peels on a daily basis, she had completely arrestedand diminished the crinkling and regained much of her loss infirmness. She was and continues to be thrilled.

I can name hundreds of patients of all ages and mind-sets thathave had similar experiences with light peels combined with gooddaily skin-care habits. With just a few simple products, thesewomen have shaved off years from their appearances. And by con-tinuing these healthy tendencies, they will maintain their youth-ful complexions longer and age far more gracefully than theywould have otherwise—even if they never take more aggressivemeasures.

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Peels 101Peels are available in three depths: light, medium, and deep. ForLevel Two skin, light peels should be sufficient. They are theleast invasive and cause virtually no redness, swelling, or irrita-tion, though they may sting slightly upon application and resultin some minor flaking for a day or so afterward. People with ex-cessively dry skin might find them to be more uncomfortableand that they can make their skin even drier. If this is the case, Isuggest cutting back on your frequency—say two to three timesa week for a home peel instead of on a daily basis. The results oflight peels are cumulative—but amazing nonetheless. Your skinwill look better and better and stay looking that way longerover time as you continue to perform them. (See photo section,page 4).

Light peels are available in three strengths:

Home: These peels contain the lowest concentration of acids asgoverned by law and so are the mildest. They are a perfect way tointroduce your skin to this type of treatment to gauge how it willreact. You even might find that they give you enough of an im-provement that you don’t need to trade up to a stronger version.Use as directed, up to once a day.

Spa: This treatment is infused with nonprescription concentra-tions of acids but is more potent than the home version and so isadministered less frequently—once or twice a month or so—toachieve visible benefits. When they are applied by a trained pro-fessional—make sure yours is—they can yield immediate resultsthat can last up to a month. The end benefits can be enhancedand maintained with home peels.

Medical: This variation contains prescription strengths of acidsand can only be performed by a trained medical professional. It

4 . I N C R E A S E C O L L A G E N A N D E L A S T I N

P R O D U C T I O N W I T H V I T A M I N C , G E N I S T E I N ,

A N T I O X I D A N T S , A N D R E T I N O I D S

Build, build, build—collagen and elastin that is. As discussed,they are the key support structures of skin and unfortunately theycontinue to decline in both quality and quantity as we age. In ad-dition to peels and the products outlined in the last chapter, mod-ern science has discovered many revolutionary and noninvasiveways to jump-start the collagen-producing machinery to helpkeep your skin smooth and youthful looking and even reversemany of the signs of premature aging. If you haven’t alreadystarted using the basic collagen-boosting, over-the-counter vita-min C- and retinol-based products discussed in chapter 3, yourskin would benefit greatly from trying them now. They not onlywill give you positive results today but will also prevent future

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may sting a bit more than the other two versions but the sensa-tion is generally slight and extremely short-lived. These peels im-part the most immediate and dramatic improvements. Your skinwill be more radiant, smooth, even, and softer immediately.Over time and with repeated application, your skin also will befirmer, your pore size reduced, your breakouts lessened, and yourlines and wrinkles softened. Depending on the condition oftheir skin and their genetic predispositions, some of my patientsget in-office peels as frequently as once a month. Getting med-ical peels more often than that is usually overkill and not neces-sarily more beneficial to the skin. Your doctor can help youdevelop a peel regimen best suited to your skin type and needs.Again, using home peels on a regular basis will extend and en-hance your results. (See “A Series of Alpha Beta Peels” in thephoto section.)


damage. If you have been using basic collagen-building productsand are happy with the results, keep up the good work. If, how-ever, you have incorporated them into your daily routine, andyou’re still noticing some unwelcome changes to your skin, youcan talk to your dermatologist about using retinoids. FDA-approved, prescription-strength retinoids can promote collagencontent in the skin and inhibit the skin’s collagen-degrading en-zymes. Renova, Retin-A, and Tazarotene are the most commonlyprescribed brands of wrinkle fighters. But while they are oftenconsidered to be interchangeable, in my experience, it turns outthat Renova is perferable. Retin-A is better at fighting acne, but itdoes work on lines and wrinkles as well.

Renova is available as moisturizing cream in a variety ofstrengths. If you choose to incorporate this product into your reg-imen, start out with the mildest version possible and graduallywork your way up to a stronger one, if necessary. Because Retin-A and Renova are more potent than retinol, their nonprescriptioncounterpart, they can cause irritation and increased sensitivity toother active ingredients and to the sun. Still, they can yield bene-ficial results. Wearing an SPF 30 will help prevent further damageand worsening of any damage you already have. If you find thatretinoids are irritating to the point that they are preventing youfrom using your other antiaging remedies, I recommend eitherusing your retinoid cream less frequently (every other day insteadof on a daily basis, for example), trying a milder, more moisturiz-ing version, or trading back down to retinol, the nonprescriptionstrength. It’s better to combat the aging process from all angleswith a variety of different ingredients (antioxidants, exfoliatingacids, vitamin C, etc.), instead of relying on a single ingredientthat tackles only one aspect.

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The (No-Injury) Laser’s EdgeA Safe and Effective Collagen Boost

I have found there to be enormous preventative as well as line-erasing and skin-firming benefits from performing a series of non-ablative (i.e., noninvasive) laser treatments on my patients of alllevels, particularly around the eyes and mouth and on crinkled ar-eas, and extensive research supports my experiences. (See “Nonin-vasive Laser for Wrinkles” in the photo section.)

The beams from the no-injury Smooth Beam, N-Lite, andCool Touch lasers spur collagen production without having toinjure the skin to do so. There is no “resurfacing” per se butrather a heat-induced stimulation to the cells that create colla-gen, called fibroblasts, which over time thickens the underlyingcollagen structure—skin is literally being built up from the in-side out. With the more aggressive ablative lasers, which we willdiscuss in Levels Three and Four (chapters 5 and 6), the surfaceof the skin is removed. It is this controlled injury that promptsthe fibroblasts to produce more collagen (see medium and deeplasers, pages 65–66).

Most noninvasive laser procedures are performed with top-ical anesthetic cream applied at least ten minutes before treat-ment. Laser treatments may cause some minimal but tolerablediscomfort. Skin in the surrounding area may be somewhat redfor twelve to twenty-four hours and faint markings in thetreated areas can remain visible for a day or two afterward, butthey can be easily concealed with makeup. Other than that,there are no other side effects to this treatment. Noninvasivesare also wonderfully effective in minimizing acne scars. I typi-cally administer a series of three to five treatments one monthapart. Results are usually visible after three months. You and

5 . R E M E M B E R Y O U R N E C K A N D C H E S T :

T R E A T I N G T H E M A S Y O U W O U L D Y O U R F A C E

My Level Two patients frequently come to me saying that theirnecks and chests look older than the rest of them. And very oftenthat can be the case. The skin in both areas seems to take thebrunt of cumulative sun exposure and seems to be more geneti-cally predisposed to becoming the worse for the wear as a result.


your doctor will decide the best course of action for you, basedon your skin’s condition and the results you want. Though theimprovements from noninvasive lasers may be subtler thanthose from deeper laser resurfacing, they can be extremely grat-ifying and permanent, nonetheless, and their preventative valueis unquestionable for areas of vulnerability, such as lines in thecrow’s-feet area, which you may have a genetic predispositiontoward developing and/or are starting to become visible, espe-cially when you smile.

Even with a good skin-care regimen that included monthlyin-office and daily at-home peels, vitamin C, and sunscreen, Claire,thirty-six, was starting to get faint lines around her eyes whenshe wasn’t smiling. Afraid of needles, there was no way she wasgoing to give Botox a shot. Instead, we did a course of threeSmooth Beam treatments, one month apart. Three months laterpeople started asking her if she had just come back from vaca-tion because she looked so well rested, and a few close friendswanted to know if she had had her eyes “done.” The collagen storesthat she has laid in as a result of the treatments not only makeher skin look better today but will also help to prevent more pre-mature aging later on. (See “Noninvasive Lasers for Wrinkles” inthe photo section.)

Returning your décolletage to its former smoother, clearer state iscompletely feasible, though—you just have to apply the samegood skin-care habits to these areas as you do to your face. And ifyou have smooth skin in these regions now, it’s a great time tostart giving them, as well as your hands, which can start to be-come problematic over the next five years, a little extra attentionto ward off future problems. Sunscreen, vitamin C, retinol, mul-tiacids, and antioxidants all can be easily incorporated into yourdaily after-bath or after-shower regimen. Using at-home bodypeels up to once a day and getting spa or medical-grade body peelsas directed by your esthetician or dermatologist are also excellentpreventative and positive measures.

In general, products formulated for the body have strongerconcentrations of active ingredients, since the chest, especially, isusually less sensitive than the face and requires a little more oomphin the treatment department. It’s fine to use facial products there,but they may not be as effective as those created specifically forthe body. Using body products on the face, though, is generallynot advisable since it can cause irritation and breakouts. Yourneck is the transitional area between your face and chest and sosome experimentation may be required to gauge whether its sen-sitivity is more like your face or the rest of your body. One morecaveat: To date, no laser, noninvasive or otherwise, has been de-veloped to safely and effectively treat wrinkles of the neck andchest.

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Food for Thought

Does Microdermabrasion Boost Collagen Production?A mainstay of many spas and estheticians, this system is com-posed of a compressor and a suction pump that work in unisonto project steril aluminum oxide crystals onto the skin with acontrollable intensity. Microdermabrasion simultaneously ex-foliates and then “vacuums” up the dead skin cells and othercomplextion-dulling debris. Like a facial, this treatment canmake skin smoother, softer, clearer looking, and minimize theappearance of enlarged pores and acne scars. But it is some-times marketed as a way to help synthesize collagen. Manypractitioners recommend a series of five to ten treatments to ac-complish this. But reputable studies have shown that micro-dermabrasion has an extremely minor impact on collagenproduction and whatever small collagen-stimulating effect itdoes have is maxed out after just two treatments.

Customizing Your Daily Regimen

Avoiding irritation and inflammation is a high priority when us-ing many different types of ingredients and procedures. It is of-ten necessary to tweak your regimen based on the season, yourtravel schedule, and whether you are taking any medicationsthat affect your hormonal balance. Irritation is not only uncom-fortable but can also accelerate the aging process. The reason?The more irritation you experience, the more your skin pro-duces free radicals. This means you might actually be aging yourskin despite, or rather because of, your antiaging regimen!

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Two to three minutes of tingling, not burning, is what Iwould call acceptable irritation because it means that your skinis accommodating to the ingredient. Any greater discomfort isreason enough to back off. Immediately discontiune any prod-uct that outright burns, causes itching, flaking, or redness.

There are a few ways to minimize reactivity to antiaging in-gredients:

Change cleansers: A real downfall to any skin-care routine is aharsh facial wash. If your skin feels dry and tight a few minutesafter toweling off, it’s time to trade down to a milder cleanser. Youmay then find that the ingredients that used to sting no longer do.

Use less: Try cutting whatever quantity you were applying in half.You might simply have been overwhelming your skin with morethan it needed. While it may seem logical, more product won’tgive you faster or better results.

Adjust your frequency: If you are using all of your products twice aday, try applying some in the morning and some at night, or tryalternating days.

Start over: If the above measures don’t seem to be helping, take abreak from all active antiaging and acne-fighting ingredients (ex-cept sunscreen) for three days or more to let your skin rest. Onceit has recovered, reintroduce yourself to one ingredient at a time.You might, for example, start your vitamin C product for oneweek; then add your home peels for a week; and lastly add yourretinol product into the mix. If all of a sudden your skin be-comes irritated, you’ll know that the ingredient you just addedback in is too strong for you. If this is the case, you can either re-duce its strength or the frequency with which you apply it, or both.

Know when to say when: If backing down isn’t helping, stop. Youmay be one of the people who simply can’t tolerate a certain in-gredient. But there are more than enough other ones out therethat will work for you.


Your specific areas of predictive vulnerability might require extrameasures. Your genetics, the way you look when you are tired ver-sus well rested, any areas of crinkling, and the lines or creases thatpop up when you make a facial expression can all indicate theparts of your face that may age faster than the rest of you. Even ifyou can’t see these problems today, taking extra precautions, inaddition to good daily skin-care habits, can significantly prolongyour years without them. And if you have the faintest hint of anyconcern, you have a huge opportunity to reverse the damage andprevent it from getting worse. If you are just noticing thesechanges now, start treating them with the strategies discussed inchapter 3. If after three months you still want further improve-ments, you can try trading up to the more potent products andprocedures below. Should any problem really stand out to you,you might want to consider taking the slightly more aggressivemeasures outlined in chapter 5 (Level 3).

I M P R O V I N G T H E U N D E R - E Y E R E G I O N

In addition to the lifestyle habits we discussed in chapter 3 thatcan cause under-eye capillaries to leak blood and create dark cir-cles, another factor can come into play now. As you get into yourthirties and beyond, the skin under the eyes, which is thinnerthan the rest of the face to begin with, starts to thin out even more,making any discoloration underneath more visible. Healing thebroken blood vessels with a vitamin K product is still an effectivemeans to reduce the appearance of dark rings, especially when


combined with bleaching agents like kojic and ascorbic acids. Butbuilding up collagen stores in this region is also advisable since itwill help thicken the skin so the circles become less apparent. Ifyou’ve already tried the over-the-counter collagen builders dis-cussed in chapter 3, pages 37–38, and still seek further improve-ments after six weeks, you can climb up the ladder in terms ofaggressiveness by adding light acid peels into your at-home skin-care regimen. The next step would be to start getting spa or med-ical grade peels and then perhaps a series of noninvasive lasertreatments. Lastly, you can talk to your dermatologist about usingRenova or Tazarotene. Because all of these courses of action en-hance collagen production, they also can have a tightening effecton under-eye puffs. These remedies are also extremely effective ineasing and preventing fine lines in the crow’s-feet area. But if thelines are more pronounced even when you are just smiling, youmight want to consider Botox injections. (See “Preventing andSmoothing Out Lines,” page 79.)

Each one of these treatments can also reap excellent benefitson its own, but in my experience, combining a few of them ismore effective, since each works a bit differently and may tackle adifferent aspect of the problem.

F A D I N G S U N S P O T S A N D O T H E R

D I S C O L O R A T I O N S

Now might be the time you begin to notice that those little brownspots that appear every summer don’t disappear in late fall likethey used to; plus you might have more than ever before. It alsomight be the time when melasma puts in its first appearance orbecomes darker if it made its debut in your twenties. While theydo take time and patience, skin-bleaching products offer a safe,

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easy, and noninvasive way to lighten these discolorations. The onecaveat? Bleaching products can increase photosensitivity and irri-tate skin, which can actually intensify the darkness in a hyperpig-mented area. But by being vigilant in your use of sunscreen andconservative in how often and how much of the cream you apply,after three to six months, these spots will be much lighter.

If you haven’t already, start by using the over-the-counterbleaching agents. If after several months, you still aren’t happywith the results, you can trade up to a prescription version. In myexperience, prescription creams that I personally formulate formy patients that contain 4 percent hydroquinone combined withkojic acid work the best. Because bleaching creams increase yourskin’s sensitivity to the sun, it’s best to use them at night. Apply tocompletely dry skin one hour before bed so the cream can’t slideinto your eyes when your face presses against the pillow. If youhave any pinkness or irritation, take a step back. Stop using theproduct and other active ingredients for three or so days to letyour skin rest. Once it has recovered, start using the cream a fewnights a week, gradually building up to every other night andthen to every night if your skin tolerates it without irritation. If itcan’t, no worries. You can still achieve some benefits by applyinga prescription-bleaching product even just two nights a week,though it will take longer.

Any especially stubborn sunspots (called solar lentigines) canbe wiped out with one to three sessions with a YAG or ruby laser.These lasers work by targeting and then destroying darker pigmentin the skin. As with the nonablative laser treatments that boost col-lagen production, a topical numbing cream is applied before theprocedure is performed so that the treatment causes only a slightamount of discomfort. Small scabs most likely will appear imme-diately afterward, but they usually fall off in just a few days. Other


than that, there is no downtime, though lasered skin is especiallysensitive to the sun and so you might require a higher SPF thanyou normally might wear. (An SPF 30 is recommended.)

While sunspots are great candidates for YAG or ruby lasers,melasma should never be treated with laser therapy. The injuryand trauma it causes the skin, though minor and controlled, justprovokes it to produce more pigment in defense.

Stacey, thirty-four, a smoker who grew up on the Jersey shore,came to me with sunspots and lines around her mouth. Believe itor not, even though she smoked, she was also a triathlete, whoregularly runs marathons. She is extremely determined but alsodeeply critical of herself. When I told her that smoking caused andintensified the lines around her mouth, she quit smoking coldturkey. From there on in, the lines didn’t get any worse, but shewanted them to significantly improve. We did a series of SmoothBeam treatments on them. In the meantime, we also did two ses-sions with the YAG to remove her sunspots. Gradually, she becamehappier and happier with the way she looked, but she became com-pletely satisfied only after seeing the results of a consistent andsolid skin-care regimen that included topical vitamin C, sun-screen, and at-home peels. (See photo section, pages 5 and 8, for re-sults of YAG and Smooth Beam lasers.)

E R A S I N G B R O K E N C A P I L L A R I E S

Zapping visible blood vessels is trickier than getting rid of brownspots and may take longer, but three to five sessions with a non-ablative Iriderm Diode Laser can fade, shrink, and even wipethem out completely. A topical numbing cream is applied before-hand so there is only slight discomfort and, except for the possi-bility of some mild bruising, there is no downtime. When tacklingextremely small areas, such as a tiny broken capillary, it’s impor-

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tant that the hand piece of the laser have a super narrow opening—about the size of a ball point pen—so that it emits the finest beamof light possible. Lasers with wider openings that give off biggerbeams of light, such as pulse-dye lasers, can increase the potentialof overlapping—when the laser passes over the same area morethan once. Overlapping, also known as doubling up, can createwhat the dermatological community refers to as the Swiss cheeseeffect—areas that are whiter than the rest of the skin becausetheir blood flow has been destroyed by excessive lasering. Thechest is particularly prone to this condition.

C A L M I N G R O S A C E A

Many women in their late thirties and early forties contractrosacea for the first time. And women who’ve had it in their twen-ties often find this condition worsens with age. If you are just ex-periencing it at this level, it is still possible to keep it at bay withlifestyle changes and over-the-counter remedies. If you have beenadhering to that regimen for at least a month and you are notachieving visible results, you can speak to your doctor about pre-scription topical and oral antibiotics and light acid peels. Oralmedications such as tetracycline, doxycycline and minocycline,all have been proven to keep rosacea’s bacterial component undercontrol and also seem to have an anti-inflammatory benefit. Top-ical products such as metronidazole and clindamycin work inmuch the same way. As discussed, acne fighters, such as benzoylperoxide and retinoids may be extremely irritating to rosacea.Light peels help to keep the skin antiseptic and combat bacteria.Several treatments with a pulsed-dye laser or intense pulsed lighttherapy, and other noninvasive treatments that target hemoglo-bin in the bloodstream, can help to eradicate the diffuse rednessthat can accompany the condition. Diode and Iriderm lasers can

zap the streaky capillaries. No laser treatment, however, is appro-priate for rosacea’s inflammatory bumps or pimples.

S H R I N K I N G E N L A R G E D P O R E S

As the quality and quantity of collagen declines over time, even ourpores aren’t as firm as they used to be. So any debris, makeup, orexcess sebum that gets lodged there can stretch out your pores be-yond a point where they can shrink back. Keeping skin clean andwell exfoliated and removing your makeup every night are simple,easy ways to help reduce pore size and prevent enlargement in thefirst place. In addition, anything that builds collagen and firmsskin, such as light acid peels, vitamin C products, retinol, and an-tioxidants will help keep pores tighter and less likely to stretch out.

M I N I M I Z I N G A C N E A N D C H I C K E N P O X S C A R S

Very often acne scars that were never really noticed before start tobother my Level Two patients. It’s not that they’ve appeared forthe first time, it’s just that as the quality and quantity of our col-

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Lasers 101While the general public believes that lasers are pretty much allthe same, it turns out that they are highly specialized in theirabilities. Do not believe claims that any one laser is capable of re-moving sunspots, erasing broken capillaries, reducing hair growth,and increasing collagen production. Different lasers specificallydesigned to tackle one particular issue perform optimally. Andany laser treatment or series of treatments is no substitute for anyof the other antiaging practices and topical ingredients.

lagen diminishes with age, any depressions in our face appeardeeper and any elevations look thicker. Any treatments that en-hance collagen production, such as peels, vitamin C, lasers, andretinol, can help thicken skin to make all scars look less visible.I’ve also had enormous success with treating depressed scars withinjectible fillers. (See “Plumping Up Creases, Wrinkles, and De-pressions,” page 84–89.)

P R E V E N T I N G A N D S M O O T H I N G O U T L I N E S

Botox injections, which have been widely publicized and writtenabout in both the beauty and scientific press, are truly one of themost revolutionary antiaging procedures the medical communityhas ever discovered. Botox is the highly purified version of thesame substance that if ingested in much larger amounts can causebotulism. But Botox used cosmetically does not cause botulismbecause it is injected directly into facial muscles (and does not en-ter the bloodstream) and is used in minuscule quantities pertreatment.

Botox was originally used by ophthalmologists to relieve eyespasms, cross-eyes, and facial tics, and doctors noticed that it re-sulted in a pleasant side effect of diminished lines in their patientswho used it. Botox is no experimental procedure; it has trulystood the test of time. The FDA approved it in 1989 for ophthal-mologic purposes and then later on to treat certain neurologicaldisorders. It has been cosmetically used with great success for thelast twelve years and was FDA approved in 2002 to treat the faciallines that result from muscle contractions. If you start Botox treat-ments just as fine lines are beginning to appear and continue toundergo them as you age, you can absolutely prevent select expres-sion lines from forming. (See photo section, pages 6 and 8.)

It typically takes around seven days to see Botox’s full benefits


and results are temporary, approximately four months. So if youaren’t happy with the way you look afterward, you will return toyour un-Botoxed appearance in just a short while. A topical numb-ing cream can be applied beforehand, based on your preferenceand your tolerance of needles. After the procedure, you should avoidlying down flat for four hours and skip exercising that day to pre-vent migration into unwanted areas. Other than the possibility ofsome slight temporary bruising, there are no side effects. Becausethe FDA prohibits conducting studies on pregnant women (as itshould) the effects of Botox on a fetus are unknown, so this treat-ment should not be performed on pregnant women.

While it is not suitable for some parts of the face or on linesthat aren’t the result of wear and tear, Botox is wonderfully versa-tile and can be used to treat and/or prevent lines that appear onlywhen you make a facial expression and the faint expression linesthat remain even when your face is relaxed. (See photo section,pages 3, 6, and 8.) Botox can even reduce deeply entrenched ex-pression lines that have been there for quite some time—thoughan injectible filler also may be required for optimum results. (See“Plumping Up Creases, Wrinkles, and Depressions” pages 84–89.)

After Stephanie, thirty-seven, had gained and then lost hertwenty-five pounds of pregnancy weight, she started to noticelines around her eyes and in between her brows, plus some sag-ging. Her mother had recently had a face-lift and since Stephaniedidn’t like its results, she was determined to do what she couldthen and there to start turning back the clock. We started her offusing peels on a regular basis to help address the sagging and to re-fresh her skin’s texture. Then we administered Botox to the linesaround her eyes and in between her brows as needed. She wentfrom looking tired all the time to looking really, really good. In-tervening at this early age might also prevent her from ever evenbeing a candidate for a face-lift.

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Because Botox is a muscle immobilizer, you should make sureyour physician is highly experienced and skilled at administeringit. There is an artistry involved in the technique. A mere ¼ to ½

inch difference in the placement site of a Botox injection canmake a huge difference in the wrinkle correction and natural ap-pearance of your face. Here are some potential risks you shouldbe aware of and discuss with your doctor:

� If Botox is injected too close to the outer part of

the brow toward the temple, it might prevent or

hinder opening that eye fully.

� If too much is placed in the forehead and/or it is

injected too far down, it can give a heavy look to

the brow and/or make the eyelids look droopy.

� The broadness of your smile may be compro-

mised if Botox is injected too far down along the

eyes to correct crow’s-feet.

� If you already have lax skin on the upper lid,

then you will be more prone to drooping eyelids

than if you don’t. If this is the case, your doctor

needs to use less Botox than usual and inject it

higher up in the forehead. It may not last as long

as the average and you may get somewhat less of

a correction, but it’s a compromise worth making

so you don’t create sagging upper eyelids.

� If too much is injected into the center portion of

the brow, closer to the nose, it can cause what is

called the wicked-looking Diablo Effect. The

outer brow shoots up to the side while the front

and center portions remain motionless.

� Botoxing the lines or wrinkles on the sides of the

nose that are exacerbated by facial contractions


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(I call them bunny lines) can give the face a less

pinched and drawn appearance. But if too much

is injected or is placed too far down, you can lose

your natural smile, since the Cupid’s bow region

of the upper lip can become paralyzed. When this

happens, it is only possible to smile with the outer

portions of the upper lip. This is why so many

young Hollywood starlets now seem to have such

strange smiles.

B O T O X C H E A T S H E E T

These Botox tips are not as complicated as they may sound.When you are interviewing a potential dermatologist about re-ceiving Botox injections, just make sure you tell him that youwant to preserve the natural architecture of your face and that youdon’t want:

� The opening of your eyes to be affected

� Your brows to slope downward or shoot up

� Heaviness in the brows

� Any drooping of the upper eyelids

� Your smile to be compromised.

I’ve read in the consumer press that if you use Botox longenough, you eventually won’t need it as often, or even at all, be-cause your muscles eventually will atrophy. Conversely, I’ve alsoread that over time, people can build up immunity to Botox so itsresults won’t last as long and you eventually will need more fre-quent injections. But in all my years of administering it, I hon-estly can say that I have found neither of these scenarios to be thecase.


Food for ThoughtIs There a Botox Replacement?

Botox in a bottle: Wouldn’t it be wonderful if you could get all ofBotox’s proven line-relaxing benefits without the sting of a nee-dle? That is exactly the thought that’s been on the minds ofmany cosmetics companies. Over the last few years, many ofthem have been introducing creams and lotions purported tohave similar line-easing effects when applied topically. WhileI am not familiar with all of them (there seems to be a new onemarketed every month), I do know that some of these therapiesincorporate heavy-metal oxides, which could minimally reducethe muscle contractions that cause the facial movements thatcreate creases. So it is conceivable that they could very tem-porarily relax superficial lines. But overall my patients who triedthese products, which are often expensive, have been dissatisfied.More research needs to be done to find the ingredients that canprovide profound and long-lasting improvements. As an additionto your regimen, these creams can offer some benefits, but theyare not a replacement for your basic antiaging regimen and cer-tainly lack Botox’s proven abilities. The one caveat? In order tobe effective, many of these preparations contain a high concen-tration of heavy-metal oxides, which can leave behind a white,powdery residue.

Myobloc, Botox’s fraternal twin? We all had high hopes for Myobloc,a purified form of Botulinum Toxin Type B. (Botox is the puri-fied form of Botulinum Toxin Type A.) It was supposed to actfaster and last longer, which would make it less expensive over thelong term, since fewer shots per year would be required to main-tain its results. Sounds too good to be true, right? Well, yes andno. Myobloc does, in fact, act faster than Botox—it takes full ef-

P L U M P I N G U P C R E A S E S , W R I N K L E S , A N D

D E P R E S S I O N S W I T H I N J E C T I B L E F I L L E R S

As recently as five years ago, dermatologists could only use fat andbovine collagen injections to temporarily plump up wrinkled orsunken areas and add fullness to a drawn-looking face. Fortu-nately over the past few years, new options have been joining theirranks—many with extremely exciting results and the research toback them up. It is important when considering which one to usethat you don’t take a chance on something being marketed as“brand new.” There are enough treatments that have been provento be safe and effective, making it completely unnecessary for youto put yourself at risk.

When you are evaluating your options, as a Level Two pa-tient, temporary should be your mantra. There are more perma-nent fillers on the market, which may seem tempting because theyare more cost and time effective since they require fewer injec-tions over the course of your lifetime. But your face is still chang-ing, and there is no guarantee how it will age around anythingforeign that has been implanted in it. Plus, if you decide later onin life that you do want to get plastic surgery, your once natural-looking permanent filler may not look that way once your skin ispulled tightly over it. I will outline the more permanent options

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fect in a couple of days as opposed to Botox’s seven. So it’s ideal ifyou want more instant gratification; for example, if you have aspecial occasion in less than a week. However, in my experienceMyobloc does wear off faster. How much faster? That varies fromperson to person. For some, it’s a matter of weeks, which makesBotox a more cost-effective option for those patients.

The Four Skin Levels

F o r e h e a d e y e s M o u t h

As the aging levels increase, the depth and number of wrinkles increase for each of the areas shown, as does laxity.

l e v e l o n e

l e v e l t w o

l e v e l t h r e e

l e v e l f o u r

Predicting How and Where You Will Age

D a u g h t e r M o t h e r

G e n e t i c s : Note how the daughter is showing similar aging patterns as her mother, particularly around the mouth and eyes.

h o w y o u l o o k w h e n y o u a r e t i r e D v s . w e l l r e s t e D

t h e C r i n k l e B e f o r e t h e w r i n k l e

s l e e p : The face as it appears when you are tired (left) showsfuture aging patterns that usually disappear when you’ve had enough sleep. Note the lines around the eyes, the increased skin laxity around the mouth, and the deepening of old acne scars on the cheeks. As you age, you may have these concerns even when you’ve had enough sleep.

p r o G r e s s i o n : Barely perceptible crinkling of the skin, often a result of sun damage, will progress to noticeable fine lines.

w i t h o u t e x p r e s s i o n w i t h e x p r e s s i o n

t h e W e a r a n d t e a r o F M o v e M e n t : As we age, lines that appear when we make facial expressions will become permanent even when we are expressionless. Botox injections help prevent this progression.

F o r e h e a d

e y e s

M o u t h

The Benefits from a Series of Alpha Beta Peels

This patient received four noninvasive peels performed monthly. Note the improvement in fine lines (eyes and cheeks), acne scars (cheeks), and overall skin tone.

B e f o r e a f t e r

The Benefits from a Series of Nonablative Laser Treatments

This patient received six Smooth Beam laser treatments for her crow’s feet. Her skin was mildly red for only twelve hours after each treatment.

a f t e r

B e f o r e

The Benefits from One Session of Botox Treatments

Botox relaxes the skin and reduces lines on the forehead as shown, but also around the eyes and in between brows.

a f t e r

B e f o r e

The Benefits from Using an Injectible Filler to Reduce Deep Lines and Folds

The patient shows nearly full correction of the nasolabial folds after receiving two syringes of Restylane.

a f t e r

B e f o r e

The Works

This patient received a combination of treatments over three months: four in-office Alpha Beta peels, four Smooth Beam treatments around the eyes, Botox in the forehead, YAG laser for sunspots, Pulse-Dye laser for the red growths, Restylane into the nasolabial folds, and daily antiaging products.

B e f o r e a f t e r

in the next two chapters (Levels Three and Four) since they maybe appropriate choices for your skin as it matures.

For now, we will limit our discussion to the temporary soft-tissue fillers, which are all injected beneath the skin’s surface toadd a youthful-looking fullness to under-eye hollows, wrinkles,the deep lines that run from the nose to the mouth, and sunkencheeks (see photo section, pages 7 and 8). The discomfort caused,the longevity of the results, and how long it takes to see the fullbenefits all vary with the substance being injected. While there isno significant downtime associated with any temporary soft-tissue filler, some short-lived bruising, swelling, and redness mayoccur afterward. Complications are extremely rare but may includeinfection. If you are pregnant, suffer from an autoimmune or a con-nective tissue disease such as lupus, you should contact your physi-cian even before consulting a dermatologist.

Collagen

Until the introduction of the hyaluronic acid-based fillers Resty-lane, Perlane, and Hylaform, bovine collagen was considered tobe the gold standard in filling. But even with younger and moreglamorous, newer kids on the block winning rave reviews, colla-gen is still widely used and the preferred filler of many doctorsand patients alike. Bovine collagen is a fibrous substance purifiedfrom cowhide turned into a liquid and then mixed with lidocaine,a local anesthetic. It is this addition of lidocaine that often makescollagen the most appealing option. While the injections can pinch,collagen is not as painful as any of the others—though any fillerinjected into the lips is painful because the lips are highly sensitive.

Because it is derived from cows, it is considered to be a foreignsubstance to the human body and can cause allergic reactions. To


ensure you don’t have one, around two months before your firsttreatment, your doctor should inject a tiny sample of collageninto your forearm (called a skin test). If redness, swelling, or itch-ing occurs within three weeks, then you are not a good collagencandidate. If none of these symptoms occur, your doctor will doanother test. If like most people you don’t have any problems,then you’ll get the green light.

There are two kinds collagen: Zyderm, which is thinner andinjected less deeply and therefore lasts a short time, and Zyplast,which is thicker and injected more deeply and lasts somewhatlonger. While it may seem like a no-brainer to opt for Zyplast overZyderm to get more bang for your buck, Zyplast can look lumpyand uneven if used in finer crevices. At Level Two, you almost cer-tainly will be more of a candidate for Zyderm since any indenta-tions you may have are most likely fairly shallow, though Zyplastmay be a more appropriate choice if you have deep creases in thenasolabial folds. As your face matures, you may want to considerusing a combination of the two.

The biggest problem my patients have with collagen is that itslongevity isn’t all that impressive. In my experience, its average life-span is about three months, and all too often it disappears in lesstime than that.

Hyaluronic Acid Fillers

Like collagen, there are different varieties of hyaluronic-acid-based fillers: Restylane and Hylaform for finer lines, and Perlane fordeeper ones. All are perfectly replicated, synthesized hyaluronicacid, which, as discussed, occurs naturally in the skin as a means offirst drawing and then trapping in water. Because hyaluronic acidis found in our bodies, you do not need to undergo a skin test forallergic reactions. I personally have gotten amazingly smooth,

86 L E V E L T W O

even, and natural-looking results from these fillers, and my pa-tients have been equally happy. My colleagues also report similarresults. Both Perlane and Restylane tend to last longer than eitherversion of collagen. Depending on the person, results can be evi-dent for up to six to twelve months. The one drawback is that nei-ther one of them is formulated with any anesthetic so a topicalnumbing cream as well as injections of an anesthetic nerve blockmay be required. (PLEASE NOTE: At the time of this writing, Per-lane is still pending FDA approval but has been widely used inEurope for years.)

Kerrie, a very tall and thin marathon runner, now forty, cameto me in her midthirties, with deep creases in the nasolabial folds,which she said seemed to have appeared overnight. They were ac-tually the result of her gaining and losing her pregnancy weight.Once her skin had lost some of its elasticity, the lines were so en-trenched she might actually have been considered a good candi-date for a face-lift, even at such a young age. Instead, we simplyfilled them in with Restylane, which plumped them back out totheir former youthful state.

For Jennifer, who was in her midthirties, the only signs of pre-mature aging that bothered her were the acne scars that seemed todeepen with age. But getting rid of them was the easiest thing inthe world. We first did a few sessions with the Smooth Beam laserto smooth and soften them and then filled in any remaining de-pressions with Restylane. The once quite prominent scars are nowvirtually invisible.

Autologus (Your Own) Fat Transfer

This treatment actually consists of two procedures so I don’t findit to be especially time or economically efficient, but it can workwonders on sunken eyes. During the first procedure, your doctor


uses a cannula—a slim probing tube attached to a vacuum—to li-posuction out a little bit of fat, usually from the buttocks, hips, orthighs. Who wouldn’t like to lose a little fat where we don’t wantit? But the operative word here is little. We’re talking 30 ccs orabout 12 tablespoons of fat. If the doctor takes enough fat outthat you will notice it, you run the risk of having a divot left inthat area and are venturing into the realm of full-scale liposuc-tion.

The tiny amount of fat is then cleansed with a saline solutionand injected into your face under local anesthetic. One of its greatbenefits is that since the fat comes from your own body, you can’tbe allergic to it. But in my experience, I have found the results offat injections to be variable. The fat can migrate into other areasof your face and so may not lie where you put it. It also generallyrequires at least two rounds of injections and, since so much ofthe fat injected into your face is absorbed by the body, it usuallyrequires the doctor to inject much more of it than you actuallyneed (called overcorrection) so you are left with unsightly bulgesfor approximately two weeks. The process is then repeated. Afterthe overcorrection diminishes, results can last longer than those ofcollagen but they are extremely variable. Considering how inva-sive this procedure is, it may not be worth it to you.

Many doctors will offer to store extra harvested fat for you forup to six months. This practice is akin to tissue banking, and it isnot one I recommend. Plus, the government frowns upon it. Thereason? There is a slight but nonetheless dangerous risk of a mix-up in the storage facility and you may get someone else’s fat in-jected into you, which can result in a reaction and even diseasetransmission. If fat injections are your filler of choice, while itmay be inconvenient and more expensive, it is best to start freshevery time.

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Laboratory-Grown Human Collagen

Recently, the FDA has approved two types of human collagengrown under laboratory conditions—CosmoPlast for deeper linesand CosmoDerm for shallow ones. Like bovine collagen, both aremixed with lidocaine to help numb the areas being treated. Un-like collagen, neither substance requires any allergy testing be-cause the collagen used is similar to the collagen normally foundin your skin. In my experience, these fillers typically have the samelongevity as bovine collagen.

Whatever line smoother or wrinkle plumper you choose to fill inproblem areas as a Level Two, it is important to keep in mind thatyou have an enormous opportunity to prevent further damageand reverse any damage that has already been sustained. The key,though, is to do nothing drastic or permanent that may not lookgood over time as your face ages and changes shape (for example,cheekbone implants, permanent fillers, or a face-lift). Your bestcourse of action is to climb the ladder in terms of aggressiveness byexploring the noninvasive procedures and antiaging products thatare geared to your specific areas of vulnerability before you doanything else. Knowing that no one procedure or product cantake the place of a healthy lifestyle and good daily skin-care habitswill also help keep your skin looking beautiful for years to come.


5Level Threey

A G E - E R A S I N G O P T I O N S

If you’re at Level Three (a score of 47–58), like many patients Isee, you may look at yourself in the mirror with the critical eyesof an adolescent. You see all the problems that need fixing rather

than all the features that make you the lovely person you are. Thefact is, however, at this phase of your skin’s life cycle, its degener-ative abilities are surpassing its regenerative ones. While this maybe a sobering if not depressing thought, do not dwell on it. Interms of turning back the clock, we’ve never had more excitingand efficacious ways to do it. And contrary to what many of myLevel Three patients—mostly people in their midforties to earlysixties—think before they start seeing me, it’s not all about plasticsurgery and/or aggressively invasive procedures anymore. At onetime, three of the top plastic surgeries—face-lifts, forehead lifts,and lower and upper eyelid surgeries (blepharoplasties)—mayhave been the most widely prescribed options for people whowere bothered by sagging, deep creases, lines, and wrinkles. True,

92 L E V E L T H R E E

they are still the only means to dramatically tighten severely sag-ging skin, but today these surgeries are just part of a continuallyexpanding menu of nonsurgical services available to us.

While according to the American Society of Plastic Surgeons(ASPS), Level Three comprises the majority of people who opt forplastic surgery, all of the above operations have become less pop-ular across the board. The ASPS reports from years 2000 to 2003,the total number of face-lifts performed decreased 4 percent, browlifts were down 52 percent, and blepharoplasties fell 25 percent.Meanwhile, the number of noninvasive Botox injections thatwere administered increased by 267 percent.

No doubt one of the major reasons for these declines is our in-creased knowledge of how to protect ourselves from the sun andfree-radical damage. New topical ingredients also build collagen,which helps to make our skin younger looking than ever beforeacross all age groups. The decline in surgery can also be attributedto the growing number of less invasive, less expensive, and morenatural-looking alternatives that are now more widely available—be it Botox, injectible fillers, peels, or laser resurfacing.

A prime concern of my Level Three patients is that they feellike they look tired all the time, even when they are well rested.This is actually due to the fact that as we mature, there is an over-all lengthening of the face. Our noses drop, the skin around thejaw descends, the fat pads in the cheeks and under-eyes fall, andgravity exerts a fiercer pull. But there is much you can do to coun-teract this downward slide without undergoing the knife. Still,don’t get caught up trying to look like an airbrushed picture ina magazine. I can tell you firsthand that for the most part, thecelebrities and models you see pictured in those glossy pages don’tlook like that way in real life. My advice to you is to focus onlooking like a healthier, more vital version of you. And listen to

A G E - E R A S I N G O P T I O N S 93

your own instincts. You alone have to decide how you want tolook, which issues bother you, and what you are willing to do toachieve your goals. Joan, fifty-two, for example, gets Botox to re-lax the lines in her forehead but leaves the ones around her eyesbecause both she and her boyfriend think they are sexy. Someoneelse might feel exactly the opposite way.

Despite social or cultural pressures, it is unwise to aim for per-fection. You have to weigh the risks of complete correction versusleaving yourself with somewhat of a line or wrinkle so you don’tlook unnatural or create a new problem that can arise as a resultof being too aggressive. Be organized and plan out with your doc-tor exactly which issues trouble you the most and how you’d liketo tackle them. But don’t do everything all at once. You mightfind that after you take care of one thing, such as relaxing the linesaround your eyes, you aren’t affected by any of the other thingsthat seemed so disconcerting before. Very often, making little im-provements such as removing brown spots, broken capillaries—evena mole—can make such a dramatic difference in your appearancethat you won’t feel the need to do anything else.

Now may not be a bad time to make more permanent adjust-ments with longer-lasting fillers, surgical implants, or even plasticsurgery if you’ve been taking the less invasive measures alreadydiscussed and are still not happy with your appearance. If thatidea appeals to you, you might first want to try the less invasivebut somewhat more aggressive measures discussed in this chapter.If you are looking for still further changes, turn to chapter 6(Level Four) to learn about more aggressive measures and aboutplastic surgery. We discuss the more permanent fillers in thischapter since they are still far less invasive than surgery of anykind. But again, take your time in making any decision and onlygo for established treatments and procedures. There are enough


safe, wonderfully successful ways to erase the signs of aging thatyou never have to put yourself at risk with something that hasn’tstood the test of time.

The BasicsIf you’re just starting out on your antiaging campaign, it’s impor-tant to realize that no one ingredient or procedure can replace agood solid daily skin-care routine with a cleanser and moisturizergeared to your skin type, gentle daily exfoliation, plus productswith proven active ingredients to increase skin-firming collagenproduction and protect your skin from free radical and sun dam-age. Below are some minor adjustments and a few simple addi-tions to the daily skin-care plans outlined in chapters 3 and 4.These substitutions and inclusions, along with the other basicmeasures previously described, can make a significant differencein helping you both to achieve and maintain a beautiful, healthiercomplexion if you use them as the foundation of your skin-careregimen. They will also enhance and extend the benefits of anyother treatment or procedure you may choose.

1 . T A K E C A R E O F Y O U R S E L F

Eating well, sleeping enough, drinking sufficient amounts of wa-ter, and getting regular exercise may sound like clichéd advice butdoing what we can to stay healthy is the single biggest beautybonus of all. You may have already noticed that you just don’tseem to bounce back as quickly as you used to from an illness, asleepless night, or one that involved free-flowing champagne anddancing into the wee hours. As we age, our built-in reserves,


which help us combat all types of stressors, become depleted. Thismakes routine aggressors like the sun, lack of sleep, or alcohol thatmuch more taxing because we have fewer and less potent internalresources with which to combat them.

I am not, by the way, suggesting that you stop having any funat all, totally cut out the foods you enjoy, give up wine, and chainyourself to the treadmill. If your overall lifestyle is healthy, skip-ping a workout, staying out late, and eating a porterhouse steakonce in a while are fine. But your body will be better able to with-stand your chosen occasional “vices” if you’ve been taking care ofyourself all along. It’s the cumulative results of our daily habitsthat have the most impact on our lives. To that end, getting regu-lar checkups, complete with blood work, and being diligent abouttaking prescribed medication will protect your health and keepyour skin looking its best. You will find more detailed health andnutrition advice in chapters 7 and 8.


If the cleanser that has always been perfect for you now leaves yourface dry, tight, or irritated, or if you’ve started reacting to a productor ingredient that never bothered you before, you are not alone. Aswe age, our skin becomes drier, more easily dehydrated, and thin-ner, which can make it more reactive. Switching to a milder versionfor sensitive, dry, or even very dry skin may be the only substitu-tion you have to make to remedy the situation. But if active ingre-dients continue to bother you, try taking the steps outlined in“Customizing Your Daily Regimen,” pages 71–72. If you still areuncomfortable, you can trade down to the nonprescription coun-terpart of an ingredient such as retinol instead of Renova. Anddon’t worry that you will no longer see results if you take a stepback and proceed with caution. As discussed, avoiding irritation


helps to prevent the free radicals that accelerate the aging process.Plus, even if they are somewhat less potent, you will still be using amultitude of active ingredients that are proven age beaters.

3 . U S E A M O R E E M O L L I E N T M O I S T U R I Z E R

Over time your skin’s natural hyaluronic acid stores and watercontent diminish. In addition, your body’s estrogen production,which is a key factor in keeping skin looking youthful, also startsto decline—notably over age forty—and your natural lipid sup-plies dwindle, which means your skin’s ability to retain moistureis compromised further. But these are actually relatively easyproblems to fix. If your skin is still dry after you change cleansers,switching to a heavier moisturizer at night is a surefire way to re-gain what time has taken away. If your face still isn’t completelycomfortable, use it in the morning, as well.

4 . B A L A N C E Y O U R H O R M O N E S

It’s been well documented that peri- or postmenopausal women no-tice many less-than-favorable changes to their skin. Concerns canrange from deeper lines and wrinkles to rough patches and increasedsagging. It has always been thought to be due to the body’s declinein estrogen, but the scientific community wasn’t 100 percent sureabout the actual role estrogen played in keeping skin looking vital.Promising breakthrough research, however, may have solved thismystery and, hence, the problem. Scientists have recently discoveredthat the collagen-producing fibroblasts in skin cells have estrogen re-ceptors, which means that estrogen plays a significant role in colla-gen synthesis. As estrogen production slows, you have less and less ofthe hormone to go to the receptors to stimulate collagen production.

A positive side effect of hormone replacement therapy (HRT),


which was originally prescribed to prevent heart disease and os-teoporosis in menopausal women and then shunned due to newresearch that showed it might play a role in breast cancer, was thatit imparted a healthier-looking complexion. It increased the skin’swater content and collagen production thus making it more sup-ple, plump, moist, and firm. Patients who went off of HRT, dueto the new health concerns, immediately noticed a difference intheir skin’s appearance.

Here, too, it is completely possible to jump-start what thebody no longer produces or that it produces in limited quantities.Genistein, the ingredient we discussed in the “Bolster Your Nat-ural Defenses” section, page 61, as a means of inhibiting the en-zymes that destroy collagen, has been shown in favorable overseasresearch to work on estrogen receptors like actual estrogen whenapplied topically without any of the side effects of HRT. Studieshave indicated that after three months of twice daily application,genistein can increase the thickness of skin by at least 10 percent.While 10 percent may not sound like all that much, biologically itis huge and so will create dramatic and visible results.

A diet that includes soy isoflavonoids has also been shown toalleviate some symptoms associated with menopause, includinghot flashes and dry skin, as well as play a role in preventing heartdisease and certain cancers. For more details on soy’s health andskin-beautifying benefits, see pages 177–79 in chapter 8.

3 . I N T E N S I F Y T H E F I G H T A G A I N S T

F R E E R A D I C A L S

Because, as we age, we have fewer natural defenses against dam-aging free radicals, it is doubly important now to use productswith combinations of antioxidants and to have adequate suppliesof them in your diet to help protect and preserve your skin.


4 . S O A K I N S U L F U R S P R I N G S

Since ancient times people have been drawn to sulfur springs,claiming a good long soak soothed their aches and pains and gavethem more vibrant and healthy-looking skin. In recent years, sul-fur, in the form of MSM and chondroitin sulfate, has been includedin supplements designed to relieve the joint pain associated withcertain types of arthritis. It is believed that sulfur plays a role inpreventing the degeneration of the cartilage (connective tissue)between joints. The connective tissue in joints is similar to theconnective tissue of skin, and indeed sulfur has also been found tobe present in the amino acids that comprise collagen. Based on fa-vorable holistic studies and research from Europe, I believe incor-porating sulfur into skin-care products and into a healthy dietcould have a huge impact on preventing the signs of aging. (Seechapter 8 for more details on sulfur’s nutritional value.) Whilethis belief has not yet filtered into mainstream skin care, I am soconvinced of its regenerative abilities that I have recently addedMSM to several products in the M.D. Skincare line. MSM is alsopresent in some creams currently sold in health food stores.

5 . R E M E M B E R Y O U R H A N D S

As with their chest and neck areas, many of my Level Three pa-tients feel that their hands look older than their faces. Unfortu-nately, hands often do have an accelerated aging process becausethey are literally skin on bone without any fat to plump them up.Your feet are the only part of the body with the same structure.The hands are also often neglected in terms of sunscreen applica-tion so, as we mature, the cumulative effects of a lifetime of sundamage can take their toll in the form of brown spots, crinkling,and rough, dry patches. But never underestimate your power to


change things. Washing with a milder soap, applying sunscreenbefore going outside, and keeping your hands well moisturizedcan greatly improve their appearance today and prevent furtherdamage tomorrow. For an even bigger boost, start treating themthe same way you do your face, chest, and neck. Put your handson a daily topical regimen of vitamin C, antioxidants, retinol, andexfoliating acids. Within months, you will see a huge difference.Incorporating at-home and/or in-office light peels, as directed,will give you even better results.

Food for ThoughtHuman Growth Factor: The Next Miracle Antiaging Ingredient?

A naturally occurring substance in skin, human growth factor(HGF) has been shown to be an important component in bothskin-cell regeneration and collagen formation. Originally re-searched as a way to heal severe wounds and burns, scientistshave been synthetically engineering the several different types ofHGF in labs or harvesting them from skin. Recently, it has be-come an ingredient used in some antiaging skin-care products.There has been concern in the medical community, however,that since some types of human growth factor may induce an ab-normal rate of cell regeneration, it could have negative effects onthe body. There have been no long-term conclusive studies tofigure out how human growth factor actually works; what hap-pens when you give people more of it than they should have at acertain age; if it’s safe; if it even works; and if so, which type andat what concentrations. Human growth factor in skin care isbeing further explored and it is also being closely watched.Stay tuned.

6 . L E A R N T O L O V E H U M I D I T Y

Dry climates, be it indoors or outdoors, literally suck the mois-ture out of skin. Humid climates impart it. Using humidifiers inyour house throughout the winter—when the air is driest dueto the cold and in-door heating systems—and in the summerwhen you have the equally skin-parching air-conditioning on—will help to keep moisture in your skin despite the dehydratingconditions.


Food for ThoughtPlumping Up Hands with Fillers

Recently, it has come into fashion to use fat injections to try tofill out a bony, less-than-youthful-looking hand. While I don’tthink this procedure will hurt you, since the fat is coming fromyour own body, I don’t know how much it can actually help. Re-member, your hands naturally don’t have any fat in them in thefirst place so adding what was never there may look unnatural.In addition, there have been few, if any, published studies on theresults or longevity of this procedure. Considering that fat injec-tions require the two-step process of first harvesting fat from an-other part of your body and then injecting it elsewhere—not tomention the necessity for overcorrection that can look unsightlyfor weeks—and then a second round of injections, I think it’s im-portant that you speak to people who have had the procedure andsee the results firsthand rather than just looking at pictures in thedoctor’s office. Before you make your final decision, speak to thesame people again three months later so you can really assess itsbenefits and lifespan.



With many of my Level Three patients, making the above adjust-ments to their daily regimen, plus adding one or two of the pro-cedures in Level Two: “Specialized Treatment for Problem Areas”pages 73–89) are all they need to be completely satisfied withtheir skin.

Hilary, fifty-three, felt like she looked tired all the time. Herdeep lines around her eyes, lax upper lids, general crinkling, andsagging around the jowls were troubling to her. Objectivelyspeaking, she could have been a realistic candidate for a face-liftor, at the very least, upper eyelid surgery (blepharoplasty). But shewas dead set against elective cosmetic surgery of any kind andwouldn’t even consider it a possibility. We did five sessions of full-face noninvasive Smooth Beam laser treatments, several in-officepeels, and a little Botox on the forehead and around the eyes. Shealso started a daily skin-care regimen that included wearing sun-screen, using antioxidant products—specifically ones with vita-min C, plus P. emblica and MSM—and at-home peels. Now, herskin tone, texture, and firmness are greatly improved, the lines farless visible, and she has a newfound radiance. She is absolutely de-lighted with the results.

Roberta, fifty-five, was so unhappy with her drooping browand lined forehead that she first consulted with a plastic surgeon,even before making an appointment with me. He recommendeda brow lift operation. The surgeon also recommended that she geta face-lift at the same time as the forehead lift because if he pulledher forehead tight enough to make an appreciable difference, therest of her face would look slack in comparison. In the end, she


still might have needed Botox to stop the wear and tear thatcaused the lines in the first place. Very frightened of plasticsurgery, especially what subjectively seemed to her to be two suchradical operations, she made an appointment with me and weopted for a series of in-office peels, solid at-home skin care, andBotox in her forehead. We could only get a 75 to 80 percent im-provement because if we used enough Botox to make her fore-head 90 percent better, it would make her upper lids and brow,both of which had a tendency to sag, droop further. Nonetheless,the results were dramatic. She was and continues to be thrilledwith the results of this game plan.

Sometimes, keeping a little extra weight on and preventativemeasures can make all the difference. Emily, fifty, was truly a ge-netic miracle. She came to me when she was forty-five, with noobvious need to tweak her regimen. She looked like she was in herthirties. Still, she wanted to prolong her youthful appearance. Shestarted using the full spectrum of antiaging ingredients in at-home products as well as getting in-office peels once a month,plus doing a little Botox on the few faint lines of her forehead thatwere just making their presence known. At the same time, shemade the conscious decision to stop trying to lose “those last fivepounds” and actually gained weight to fill out her “fashionably”ultrathin frame and face. She still has a great figure, by the way.Her friends and husband were completely perplexed and not allthat pleased that she was spending so much time and money try-ing to eradicate skin problems she clearly didn’t have. Five yearslater, everyone is amazed at how fantastic she looks, especially incomparison to her peers. She truly could pass for thirty-five.

So if there are things about your face that you’d like to change,and you feel the need to kick it up a notch from the strategies out-lined in the last chapter, you can try trading up to the strategiesoutlined below, which may simply be a matter of combining a few


of the Level Two measures. If you still are less than thrilled, youmight want to consider the more aggressive tactics described inchapter 6 (Level Four), where you will read about Virginia, fifty-two, extremely youthful looking in every way except for theprominent lines around her mouth, who opted to go all out withdeep laser resurfacing.

R E L A X I N G L I N E S A N D P L U M P I N G U P W R I N K L E S :

B O T O X A N D F I L L E R S

If you’ve already tried using Botox or a filler for specific regions ofconcern, you might be finding that using either one alone isn’t of-fering you a satisfying enough correction. And if you’re just start-ing out, your doctor may advise you to treat certain lines andwrinkles with a one-two punch of both injectibles. The reason?Lines that are the result of wear and tear from facial contractionsmay still be visible now when your face is no longer making an ex-pression. Conversely, lines that are plumped up with soft-tissuefillers may no longer be visible when your face is at rest but appearwhen you are making an expression. If either one of these scenar-ios is the case, I recommend first treating the area with Botox tominimize the wear and tear that caused the line in the first placeand then a filler to plump up any remaining depression. Thedepth of the line or crease will determine which type of filler willbe the most effective. The thicker Perlane and Zyplast are perfectfor deep creases, such as the nasolabial folds, entrenched wrinkles,and acne scars. Zyderm and Restylane are better for finer lines.Getting Botox before any filler will also increase its longevitysince it won’t be worn away as quickly by muscle contractions.

Sometimes a line can exist within a crease. If this is the case,first have it filled in with the thicker Perlane or Zyplast. Wait aweek to see the effects, and then layer Restylane, Zyderm, or Cos-


modem into the remaining line. Different areas of the face oftenrequire different filling, Botoxing, and other antiaging tactics.Here are some specifics.

The Nasolabial Folds

For the deep creases that run along the sides of the nose down tothe mouth, soft tissue fillers are, for now, the best game in townunless you opt for a face-lift to pull them upward and outward(see photo section, page 7). However if you seek to completelyeradicate those creases through plastic surgery, you may have to bepulled extremely tight, which can result in an unnatural look.

In terms of fillers, generally the thicker Perlane and Zyplastoffer the most satisfactory results in this region. Medium to deeplaser and peel resurfacing (see “Reducing the Appearance of Lines,Lightening Sunspots, Tightening Lax Skin, and Spurring CollagenProduction in One Fell Swoop,” pages 115–120, for more detailson those treatments) cannot firm up severe sagging and can evenbe dangerous if either one is cranked up to the intensity wherethey could theoretically burn the skin. Permanent scars, burns,hyperpigmentation, and hypopigmentation are just a few of theside effects that could result. Botox is also not an appropriate treat-ment for this area.

Brow and Forehead

Botox is still the best option for easing lines in the forehead andthe muscles between the brows, called the glabella, (see chapter 3,for specifics). Fillers may be used to some extent in the glabella.Forehead lines, on the other hand, have no anatomical valley tofill in, so only Botox works well there. (See photo section, page 6.)Fillers may be used in the glabella to some extent, but it can be a


tricky business because it contains a complex network of bloodvessels. If you inject too much filler too deeply, there is a rare butserious risk that it could temporarily cut off circulation to thearea, which can cause ulcerations of the skin. Using a moderateamount of Zyderm and Restylane injected very superficially canplump up any loose, flaccid skin in the areas that look differentfrom the rest of the forehead. You can get really good results withjust a tiny amount. It is far better to keep a little bit of a line thanto push the hand of your doctor to go deeper. A light hand isequally important when filling in bagginess in the glabella. Youdon’t want to risk having it puff out over the bridge of the nose,which can create a Neanderthal effect. (See “Reducing the Ap-pearance of Lines,” pages 115–120 for all Botox specifics.)

Crow’s-Feet

Peels, Renova, and nonablative laser treatments may not beenough to give you completely satisfying results now, but eachone of them will still make a difference, especially when used incombination with one another. Botox to stop the wear and tearthat causes the lines would be your next addition. When seekingto soften the lines around the eyes, it’s important to make sureyou don’t completely immobilize the lines that appear when yousmile or talk. Otherwise, you may compromise your ability toopen your mouth normally. To treat this area safely and effec-tively, your doctor should inject three shots at the very corner ofthe outer eye 1⁄16 inch below the bone of the eye socket spanningno more than ½ inch vertically down to the top of the cheek-bone. The three injections should be no more than 1⁄4 inch apart.While this precision may be a bit nitpicky, it is necessary to avoidcomplications. When Botox is injected too low in the face, it candisable the cheekbone muscles. When this occurs, your smile is


greatly affected since your cheeks won’t rise and your upper lipwon’t turn up at the corners when you smile. If you look at someyoung Hollywood starlets who suddenly seem to have peculiarlooking smiles, it is most likely because they have had Botox in-jected improperly into this region or into the bunny lines (thelines or wrinkles on the sides of the nose that are exacerbated byfacial contractions). If you have puffy under eyes as well as lines,talk to your doctor about placing the injections farther horizon-tally out to the ear. This way when you smile, your eyes will stillstretch outward a bit so the puffiness will spread out rather thanaccumulate in a smaller area.

For more correction, you can try some nonablative laser treat-ments, done after the Botox injections so you can see the regionsthat require extra attention. Any remaining lines can be treatedwith the thinner Restylane or Cosmoderm after the laser treat-ments so the heat from the laser doesn’t break either filler down.The thicker Perlane and Cosmoplast can create bumps and un-even results in this area since the skin under the eyes is especiallythin. For a more aggressive laser procedure, see “Reducing the Ap-pearance of Lines,” pages 115–120.

The Lips

While many younger women want to make their lips plumper,thinning lips can become more of a major concern for my LevelThree patients. Injectible fillers such as collagen, Perlane, andRestylane, can create believably attractive-looking fuller lips ifyou and your doctor are moderate in your expectations. The star-lets with the overblown bee-stung pouts are typically going forthis look to create a certain effect on camera. It doesn’t necessarilytranslate into real life situations. Often, fat injections (see chapter 4,Level Two for more details) are recommended to plump up this


area but, given that the treatment requires two procedures and tworounds of injections with overcorrection that leave you with un-sightly bulges for approximately two weeks after each one, youmight want to consider the easier-to-use and more efficient colla-gen or hyaluronic acid-derived fillers instead. In my experience, Ialso have found the results of fat injections to be variable becausethe fat can migrate into other areas of your face.

Lines above the upper lip can be especially troubling forwomen as they age because as they become deeper, lipstick canstart to bleed into them. If nonablative laser treatments and lightpeels aren’t giving you the results you want, you can trade up tomedium-depth laser, resurfacing, or peels. Injecting fillers intothese lip lines can also yield highly successful results, particularlyif your doctor injects the filler into the perpendicular lines aroundthe border of the lips. These lines are often neglected when theoverall mouth is being treated because they are fairly faint in com-parison to the others. But plumping them up (even if you don’tget a filler administered anywhere else in the skin above the upperlip) will significantly rejuvenate this area. It will also help to pre-vent your lipstick from bleeding.

T H E M O R E P E R M A N E N T P L U M P E R S

If the idea of a lifetime of regular filler injections is less thanappealing, it may be tempting to consider some of the more per-manent fillers. For now, these include Radiance, Artecoll, and sili-cone. Permanent, however, is a relative term. While silicone hasbeen proven throughout the years and in numerous clinical trialsto be permanent, no long-term studies on the longevity of Radi-ance and Aretcoll are available since these substances haven’t beenused cosmetically for a long period of time. But since they are longerlasting than anything else out there and may require surgery to


have them removed, it is paramount that you select a doctor whois highly skilled in administering any of the above-mentionedfillers. So far, studies have shown that these more permanent fillersare good in deeper grooves, such as crater-like acne scars and thenasolabial folds. It is very hard to get good results for lip lines andlip plumping, crow’s-feet, and lines in the forehead. While I haveseen some good results with these more permanent plumpers, hor-ror stories in medical journals abound. So proceed with caution.

In addition to speaking to as many people as you can who’vehad any of these treatments, I also recommend that if you decide togo for it, only correct a little bit at a time; then wait for six weeks,see the results, and gradually add more if need be. Never aim forfull correction in one sitting. It may be more expensive and timeconsuming than having it all done at once, but it is one way to en-sure that you will be happier with the results. Another way to makesure that you are the rule rather than the exception is to hedge yourbets and go the conservative route. Ask your doctor to “perma-nently” fix only 80 percent of a concern rather than the whole nineyards. You can always supplement the results with temporary filler.

None of these permanent fillers are so far approved by the FDAfor cosmetic use, but silicone and Radiance are FDA approved forother medical purposes. So if you choose to go the more perma-nent route, at least there are reputable, legitimate suppliers of thosetwo substances that have to adhere to rigorous testing standards.

Liquid Silicone Microdroplets

Once only associated with breast implants that were potentialhealth risks, silicone has recently been FDA-approved for oph-thalmologic use (Aldatosil) and is currently being considered forreinstatement as a material for breast implants, as long as the


manufacturers take the necessary steps to prevent the implantsfrom leaking into the body. Silicone’s true plumping benefitscome from spurring collagen formation in much the same way agrain of sand sparks an oyster to create a pearl. Once silicone is in-jected, the body encapsulates each microdroplet with its own col-lagen, forming a tiny skin-plumping scar around the particle. Thebiggest problem with liquid silicone microdroplets as a cosmeticfiller is that sometimes excessively large-volume shots are incor-rectly injected, resulting in severe overcorrection, migration, andinflammation. Worse still, large sometimes painful, nodules oc-cur, which very often can’t even be surgically removed. A doctorwho administers silicone microdroplets must be skilled in the artof undercorrection and be able to gauge how much silicone isneeded to produce an appropriate collagen response to fill in agiven area. The results are permanent.

Radiance

Made from calcium hydroxyl apatite, a natural component ofbone and teeth, that has been synthesized into injectable micro-scopic spheres, Radiance has been FDA approved for use in thelarynx and has been used in Europe for the past few years toplump up lines and scars, fill in nasolabial folds, and for lip en-largement. Initial studies indicate that Radiance appears to havelittle or no risk of allergy when used cosmetically and may last aslong as five to seven years.

While you will see an improvement immediately after theprocedure from the injection of the material itself, Radiance’s mi-crospheres spur collagen production in that region in much thesame way as silicone microdroplets do—so it might take a fewmonths for you to realize its full benefits. As with silicone, a doc-


tor who uses Radiance must undercorrect and judge how muchRadiance is needed to spur the right amount of collagen growthto plump up a given region. Otherwise, the results can lookoverblown and unnatural. Studies suggest that the microspheresdisappear over the years, leaving your collagen as a semiperma-nent effect. Touch-ups may be required. Specific FDA approvalfor cosmetic use is expected in the near future.

Artecoll

This consists of a mixture of plastic microspheres, bovine colla-gen, and the anesthetic lidocaine. The collagen gives you more ofan instant-gratification effect and then dissipates after a fewmonths. The plastic microspheres remain indefinitely, promptingthe body to produce collagen and scar tissue around them. WhileI have seen some good results when used in depressed scars anddeep creases, there is a high incidence of bumpiness when Artecollis used for lip augmentation. Again, the key to getting successfulresults is to undercorrect to allow for the skin’s natural collagenformation to fill in an area rather than the Artecoll itself. Unfor-tunately, if you have any problems with it, the sphere has to besurgically removed, which could result in scarring.

U N D E R - E Y E B A G S A N D D A R K N E S S

Other than the treatments outlined in chapters 3 and 4, and a bleph-aroplasty (surgically removing the vascular fat pads under theeyes that can erase darkness as well as deflate puffiness), these is-sues are pretty tough to tackle. As discussed, light peels, nonabla-tive laser treatments, Renova, genistein, and vitamin C all canhelp to thicken skin so that the fat pads and any fluid accumula-


tion have less of an opportunity to push skin outward. If you areonly recently troubled by under-eye bags, and you are not genet-ically predisposed to them, you might want to talk to your doctorabout having your thyroid tested.

Medium laser resurfacing with an Erbium laser can tighten skin,erase crow’s-feet, and, to a lesser extent, lighten under-eye skin.

G E N E R A L S A G G I N G

Unfortunately, other than a face-lift, there are few options forfirming up sagging skin, since fillers aren’t appropriate for thisproblem. The less aggressive radio-frequency face-lift mighteventually deliver the tightening results we’ve all been hopingfor; but for now, building collagen through light peels, vitaminC, retinol, sulfur, and genistein while protecting your skin fromthe sun and free radicals with sunscreen and antioxidants is yourbest bet and still can deliver considerable improvement. I’ve alsohad some success with treating overall slackness with severalnoninvasive Smooth Beam full-face treatments and with themedium-depth Erbium laser.

Food for ThoughtThe So-Called Knifeless Face-Lifts: Too Good to Be True?

Electrostimulation: While this treatment has been a mainstay ofspas and dermatologists’ offices for several years, it frequently en-joys a resurgence in popularity. These days, it’s being billed as analternative to Botox. Little electrodes are placed on your face and


then a low level current is turned on to stimulate muscle con-traction. (Botox, on the other hand, stops it.) The idea behindthis treatment is that if you can stimulate a muscle contractionmaximally, it will stay that way, which will pull the skin up likea face-lift. Sort of like if you build a muscle through weight lift-ing, it will pull the skin tighter since it has to stretch to fitaround it.

This logic might hold somewhat true for stimulating themuscles in the cheeks because you are contracting them in the samedirection that a face-lift would pull up excess skin in the naso-labial folds. Results, however, in the best-case scenario, have sofar been proven to last only a very brief time. Some studies re-port a beneficial lift of the eyebrow. The forehead, on the otherhand, is an entirely different matter. Electrostimulation actuallycontracts the muscles in the same way that we wrinkle our fore-heads, raise our eyebrows, and scowl. Making those facial ex-pressions is what leads to the wear and tear that causes the linesin the first place.

Why artificially induce more of them? While some maintainthat facial exercises work in much the same way as electrostimu-lation, I have never seen them work on any of my patients, norhave I seen any research proving their effectiveness.

The radio-frequency face-lift Known by the trade names Therma-Cool and sometimes Thermage, this treatment uses a handheldinstrument to transmit an electric radio frequency through theskin to heat the collagen fibers below the surface causing them tocontract and tighten, without burning the top layers. Thepremise is that radio frequency can heat the skin at higher tem-peratures than lasers can without burning the skin so it has moreof a tightening effect than they do. Studies presented to theAmerican Society for Laser Medicine and Surgery (ASLMS)have cited 25 to 50 percent improvements in tightening mild tomoderate laxity in the nasolabial folds, forehead, the skin sur-


rounding the eyes, and jowls. So it could quite possibly be “thenext big thing.”

But while the radio-frequency face-lift is garnering somebuzz for being a breeze of a procedure, it isn’t exactly painless.While the pulses of energy are being delivered, a cryogen coolingspray is simultaneously administered to help keep the surface ofthe skin from burning and minimize discomfort. But more anes-thetizing is generally required. A topical numbing cream is alsoapplied and local anesthetic injections administered. Some doc-tors are now also giving patients Percocet, intravenous sedation,or nerve blocks to help them manage what some anecdotal re-ports cite as intense pain. Reports on the downtime vary fromno redness or discomfort at all to a week or more. So for now, itis difficult to gauge how long it will really keep you out of com-mission.

ThermaCool is FDA approved for treating laxity in theupper third of the face, with approval pending for the lowerportion. While some doctors are raving about the results, the pro-cedure is still in its infancy. Follow-up information on patientswho have had it is based on only a few years, so potential long-term complications may not have had the chance to surface. Inaddition, the longevity of its results hasn’t been established. It isalso worth noting that so far it has only been shown to be bene-ficial in treating mild to moderate signs of aging and is not asubstitute for a traditional face-lift. CO2 and Erbium laser resur-facing are still recommended to treat more deeply wrinkled, sun-damaged skin.

If you do decide this is the procedure for you, again, I sug-gest you talk to as many people as possible who have had it soyou can get an accurate picture of what it entails, what the endbenefits are, and what the healing process is like. Before-and-after photos may show exciting results but they don’t reveal thefull picture. Time may prove radio frequency to be a valuable ad-dition to the antiaging arsenal, particularly if the treatment is


fine-tuned so it is less painful and improves more dramatic sag-ging. I, for one, am going to wait it out.

Coblation Short for cold ablation, this procedure, like radio fre-quency, uses a microelectrical radio frequency. But rather thanspurring collagen production through heat stimulation to the fi-broblasts, it actually disintegrates surface-damaged skin, likemedium and deep laser and peel resurfacing. The formation ofnew collagen is the result of the skin’s healing from this injury. Ihave only seen soft data based on poor clinical trials claimingCoblation’s safety, effectiveness, and longevity. I have also treatedtwo patients for scarring and burns as a result of this procedure.In addition, while the pain and downtime have been likened tothat of nonablative procedures, anecdotal reports cite it to be farmore like those of deep resurfacing treatments. As with the radio-frequency face-lift, this procedure is still in its infancy so follow-up information on patients who have had it is based on only afew years. Potential long-term complications may not have hadthe chance to surface. In addition, the longevity of its resultshasn’t been established. If you are considering coblation as anoption, I would urge you to do your homework and speak to asmany patients who have had it as possible before you make yourdecision.


Reducing the Appearance of Lines, Lightening Sunspots,

Tightening Lax Skin, and Spurring Collagen Production

in One Fell SwoopIf you’ve already tried the full spectrum of nonablative lasers andlight acid peels and are still not completely satisfied with yourskin’s overall appearance, it might be time to consider resurfacingwith a medium laser or peel. Unlike their lighter counterparts,which spur collagen production either by direct stimulation tothe fibroblasts (laser) or from the chemical fluctuation of the skinas it goes from acidic to neutral (peels), medium peels and laserresurfacing actually disintegrate the damaged skin to “remove”wrinkles, discolorations, age spots, and crinkling. This controlledinjury causes new collagen to form as the skin heals, making a facelook smoother and more youthful as a result. They both also havesomewhat of a tightening effect. And while you still may needBotox for remaining lines, and soft-tissue fillers in deeper inden-tations, medium resurfacing is an efficient and long-lasting way totreat several different issues simultaneously. Typically these treat-ments are performed only once every five to ten years as needed,but if you have a lot of sun damage, your doctor might recom-mend two treatments done in relatively quick succession. Deeperlaser and peels should be performed before you receive any soft-tissue fillers or Botox.

The degree of improvement depends on the strength of the


peel or laser, the depth they penetrate, and the extent of the dam-age before treatment. But going all out can have its downsides—the higher the heat of the laser or the strength of the acid, thegreater the risks, which might include scarring, hyperpigmentation,and hypopigmentation, especially around the eyes and above theupper lip. Medium, dark, and olive-toned skins are especiallyprone to hypopigmentation and hyperpigmentation—the darkerthe complexion, the greater these risks. Sometimes, both side ef-fects can occur even if the peel or laser treatment is relativelymoderate. There really is no way to darken the areas that have be-come hypopigmented, though sometimes you can successfullybleach the hyperpigmented ones. All too often, the aftermath ofoverzealous resurfacing, particularly in places that have been over-lapped (where the chemical solution or laser has passed over morethan once), is permanent, may not be concealable with makeup,and looks worse than the original lines. It is important to discussthese risks with your doctor and to proceed with caution and un-dercorrect, rather than trying to completely wipe out every lastproblem and push the odds.

But enough of doom and gloom. If done right, medium-strength peels and lasers offer tremendous overall benefits. Thetrade-off for these benefits is that, unlike their noninvasive coun-terparts discussed previously, these procedures do require a recov-ery time.

For a medium peel, your doctor will most likely swab on amixture of trichloroacetic acid followed by a neutralizing solu-tion. Medium laser resurfacing uses a carbon dioxide (CO2) laserturned down lower than for deeper projects. I personally prefer thesomewhat less aggressive Erbium laser. Both procedures are per-formed under local anesthetic through topical cream and injec-tions. You may be given a prescription for an antibiotic andantiviral medication to help prevent infection and possibly corti-

sone to help prevent swelling. Your doctor will advise you whenand for how long you should take them.

While recovery time varies with skin type, your own naturalhealing abilities, and the depth of the procedure, skin typically re-mains oozy, swollen, and weepy for three to five days. Your skincan stay red to pink, which can be covered up with makeup, foran additional two weeks. I recommend you wait till any rednesscompletely recedes before using any products other than a gentlecleanser, sunscreen, and a fragrance-free moisturizer. It is also crit-ically important to avoid sun exposure, which can cause hyper-pigmentation in recently peeled or lasered skin and to wear atleast an SPF 30 when you are outside.

Mona, fifty-six, felt that small, gradual changes from at-homeproducts and light peels just wouldn’t give her the more dramaticchange she was looking for. A CEO at a major company, she felt thatshe needed to stay young looking to hold her own in the highlycompetitive business environment. She was not a candidate for aface-lift. About eight to ten pounds overweight, her face was rela-tively plump and firm—she simply didn’t have enough excess skinto pull back. If she had that little bit “lifted,” her face would havelooked unnaturally “tight.” We opted to do full-face Erbium laserresurfacing to give her a jump-start, so to speak. She got great results.Her skin was less lined, more even, radiant, and even firmer. She’sbeen maintaining these results, which made her completely happy,for the last several years with in-office peels, daily home Alpha-Betapeels, and other products containing the key antiaging ingredients.

R E G I O N A L R E S U R F A C I N G

Sometimes, it is possible to treat just one particular area, such aslines on the upper lip, if a full-face procedure isn’t necessary. Atthis level, working regionally can be highly effective. As you ma-



ture, however, limiting treatment to just one area may make itlook out of sync with the rest of the face. I also don’t recommendregional treatments for people with medium to dark skin tones asthere could be a marked change in skin pigmentation between thetreated and nontreated areas.

C H O O S I N G B E T W E E N T H E T W O

Since medium and deep peels and laser resurfacing have the samerisks and downtime, it may be difficult to decide which treatmentto go for. I personally favor medium and deep laser resurfacingover medium and deep peels. I find that the laser offers more ver-satility. For example, you can turn it up a bit higher to treat moredamaged areas and then gradually taper it back down for the restof the face. A peel works uniformly so your only option is to rubit on harder in some places than in others, which can increaseyour risk of scarring, hypopigmentation, and uneven results. Butyour doctor can help you decide your best personal plan of action.In either case, it is important to make sure your doctor is highlyskilled with a lot of experience in the procedure you choose. Nei-ther method can cure sagging, including under-eye bags, becauseif the laser is turned up too high or the peel is too acidic, there isa huge risk of burning and scarring.

T H E N E C K , C H E S T , A N D H A N D S — E S P E C I A L L Y

T R I C K Y A R E A S

In my experience, the downsides of aggressively treating lines andwrinkles on these parts of the body far outweigh the benefits. Theskin there, especially prone to mottling, brown spots, and brokencapillaries from sun damage, is also very susceptive to the scarring,hyperpigmentation, and hypopigmentation that can be caused by


medium to deep peels and laser resurfacing. I have also found thattreating them with nonablative collagen-stimulating lasers doesn’treally do all that much. The good news is that you can removemost of the obvious imperfections, which will make these areaslook more youthful and healthy. While it may be impossible tocompletely turn back the clock in these regions, modern science ismaking strides every day. Promising wrinkle-treating lasers for theneck and chest are in development. Still, most of my patients findthat just by conquering the most visible issues, they become com-pletely satisfied with the appearance of their neck, chest, and handsand are no longer troubled by any remaining imperfections.

A YAG laser can wipe out the sunspots on the chest, arms,back, and hands. Broken capillaries can be zapped with a diodelaser. Those red specks, called hemangiomas, that appear on thechest can be burnt off with an electrocauterization, which literallytakes two seconds, causes little to no discomfort, and has nodowntime except for tiny scabs, which fall off within days. In ad-dition, at-home, spa, and in-office light acid peels can provideimprovement in texture, clarity, and firmness in all of these re-gions but requires several months of treatment. Visible veins thataren’t functional may be rendered less visible by two to three ses-sions of sclerotherapy—a saline solution is injected into the veinsto collapse them. Tinier ones can be vaporized by a few sessionswith a laser.

The neck is especially prone to sagging and deep lines as a re-sult of genetics, dramatic weight loss, or sun damage. In terms oflines, it can have both vertical and horizontal ones. The verticalones occur as the result of wear and tear from muscle contractionsand so can be eased by Botox injections. The horizontal ones, onthe other hand, are the result of sun damage and genetics and soare not good candidates for Botox.

The only thing that can truly help severe sagging there is a


neck lift by a plastic surgeon. But proceed with caution as they arenot always permanent and can offer varying results. Botox canprovide a satisfactory but temporary alternative. It can relax thecords or bands that protrude from the neck that tend to sag withage and pull the neck downward. Once they are eased, unopposedupward muscular movement raises the neck, giving it the appear-ance of it being somewhat lifted.

Renee, fifty-seven, is a very thin woman with extremely thinskin. While her very high, prominent cheekbones could some-what support the skin in her face to prevent it from sagging dra-matically, there was no such structure in her neck. She was sobothered by her neck that she kept her blouses buttoned up to thevery top button and began to favor turtlenecks. She was consider-ing a neck lift but in order to achieve the most natural looking,symmetrical results, she was advised that she would also need afull face-lift or her neck would look completely out of sync withthe rest of her face. Instead, we did several Botox injections in theneck, and it gave her enough of an improvement that she is nowwearing scoop and V-neck tops.

Don’t Underestimate the Powerof Small Changes

Sometimes, the most minor adjustments can have a major im-pact. Ann, fifty-eight, was really bothered, and I mean really both-ered, by the lines on the skin above her upper lip. We took theleast invasive route first and treated them with several sessions ofthe Smooth Beam nonablative laser, which gave her a moderate


improvement. She still wasn’t 100 percent happy so we usedRestylane to plump up any remaining indentations, which gaveher even better results. However she was really aiming for perfec-tion, which can be risky. I didn’t want to get more aggressive withdeep peels or laser since there was a good chance that either treat-ment would cause hypopigmentation, which would have lookedworse than the lines. She found the answer herself and just got herteeth whitened. Low and behold, she has the most gorgeoussmile. Now when you see her, you never notice any lines aroundher upper lip—not only have the lines been significantly reducedbut she’s also flashing this dazzling smile with her beautiful pearlyteeth.

Imperfections can be rendered virtually invisible if there issomething else wonderful about you. We know it to be the casefor the personalities of the people we love. And the same holdstrue for the way you and other people perceive your appearance.Here, little alterations that can make a big difference:

� Be Colorful: Wearing color—any color—instead

of black, white, or beige near your face can make

you look like you’ve been getting eight to ten

hours of sleep every night. If your style is shifted

strictly into neutral, try wearing a bright scarf or

colorful necklace.

� Change Your Hairstyle: Wearing long bangs,

sweeping your hair to one side versus wearing a

center part, and trimming it to shoulder length

can all give the illusion of a fuller, i.e., younger-

looking, face. Adding a little volume rather than

blow drying it straight can also make you look

more energetic.


� Play with Your Hair Color: Traditionally, the beauty

industry has counseled women to lighten up their

hair color as they get older. Going a shade or two

lighter, or adding highlights around your face

definitely can liven up the complexion. Going

too light, however, can have the opposite effect.

One of the things that gives the face luminosity

is contrast, as in the contrast between your skin

and hair color. If your hair is virtually the same

color as your face, you will no longer have any

complexion-brightening contrast.

� Experiment with Makeup Shades: Dark, super

bright, and very pale pastel shades can make

anyone look tired. Soft hues with some depth to

them such as plums, chocolates, medium char-

coals, rose, and medium pinks, on the other

hand, will make you look more vital. If you are a

die-hard red lipstick fan, adding more depth to it

while downplaying some of its harshness by

applying a light brown lipstick on top can make

all the difference. The same goes for fuchsia and

orange.

� Brighten Your Smile: In addition to bleaching your

teeth, wearing a blue-based (cool-toned) lipstick

can make your teeth look whiter and the whole

face look younger and more vibrant as a result.

Yellow-based lipsticks (orange, coral, peach, etc.)

can have the opposite effect.

� Wear Less Makeup: Too much foundation and

powder can settle into lines, creases, and pores,

calling more attention to them, rather than cam-


ouflaging them. This can happen, by the way, to

women of all ages. Layers of makeup can also

make skin look overly matte, which definitely

can suck the life right out of it. Try spot con-

cealing over the places that need a little extra

attention rather than wearing a full face of

foundation.

� Think Dewy: Moisturizing and creamy formu-

lations with a very subtle shimmer can make for

a smoother makeup application while giving skin

that “lit from within glow.” Matte formulations

are drying, plus they not only fail to impart

light, but they also can rob you of it. Super shiny

products with a white pearly opalescence can

have the same effect.

� Soften Your Eyebrows: Super thin eyebrows can

look severe and age the face. Somewhat fuller

ones can erase years. If you don’t have the

patience to grow them back in, or find that years

of plucking have stunted their growth cycle, use

feathery strokes of a pencil one shade lighter than

your hair color to fill them in a little bit. Bushy

brows aren’t the goal since they can also be aging;

aim for softly full eyebrows.

Small cosmetic changes can all do wonders in terms of revi-talizing your appearance and your self-confidence. So can embark-ing on a sound daily regimen that includes proven preventativeand age-reducing measures, such as wearing sunscreen, using an-tioxidant products to guard against free radicals, acids to exfoliate,and vitamin C and/or retinol to spur collagen production. All


these measures can still greatly improve the condition of yourskin. When considering doing any of the more aggressive thera-pies we have already discussed, it is important not to let the me-dia or your peers push you into making a rash, rather than alogical, decision. And once you have decided what improvementsyou wish to make, be organized and plan out your strategy ratherthan just randomly jumping into a procedure or product. Doingone thing at a time, rather than all at once, is also key. Fixing oneproblem, such as easing the furrow between your brows, may beall it takes to give you the results you were looking for. Plus, veryoften making little improvements such as removing brown spotsor broken capillaries can make a dramatic difference in makingyou look more youthful.

My most important advice to you, especially at Level Three, iswhile it may be tempting to jump right into a new so-called mir-acle cure, don’t buy into unproven hype. Go for what is tried andtested with proven results. Never put yourself in the position ofbeing a guinea pig; your health and your face could suffer majorconsequences as a result. Besides, with so many safe and effectiveantiaging options out there, you can achieve a younger-looking,smoother, and more vibrant complexion without any risks at all.

6Level Foury

M A J O R C H A N G E S . . . O R N O T

M any women who are entering their sixties or seventies,at Level Four (a score of 59+) are feeling very positivelyabout their looks and their lives. They have so much

more self-confidence than they’ve ever had before—be it from lifeexperience, successes at work, raising children, etc. In addition,they now feel more energetic and vital since their families havegrown up, their careers are winding down, and they have morefree time than they’ve had in years. Generally, they are happy withand are less focused on their appearance. They’ve made peace withthe aging process of their skin and so don’t have the desire to un-dergo anything drastic or invasive—especially if they or someoneclose to them has had to have any kind of a medical procedure.Perhaps this explains why Diana, a sixty-seven-year-old grand-mother, scored a Level Two on the Life Cycle Quiz compared withher daughter, twenty-five years younger, who scored a Level Three.

Irene, sixty-eight, for example, made an appointment with meonly because she was feeling pressured to “do something” to herface because a lot of her peers were getting plastic surgery. Up un-til that point she had been happy with her appearance. But now,all of a sudden, she was feeling insecure in comparison to herfriends. But she also honestly felt they looked unnatural and wasnot an advocate of elective cosmetic surgery in the first place. Wegot her on a Level Two regimen of at-home peels, sunscreen, andvitamin C–based products, which all levels should be using daily.After several months, she was delighted with the results. She maynot look as “young” as some of her friends, but she looks health-ier and refreshed—a more vital version of herself, which waseverything she had hoped for.

Many of my Level Four patients also have completely revisedtheir priorities saying things to me like, “My cataract surgery lets mesee now better than ever and I’m just so happy to be able to read andsee clearly again. What do I care if there are lines around my eyes?”

On the other hand, some of my Level Four patients, espe-cially those out in the workforce in competitive fields, feel likethey want a more dramatic change, in order “to compete better”or simply to “look as young and energetic as they feel.” Alicia,sixty-two, is an example. Not completely happy with her appear-ance, she came to me ready to make some changes. We workedher way up the ladder in terms of aggressiveness—lasered offbrown spots and broken capillaries, used Botox in the linesaround her eyes, Restylane in the ones above her lips, and put heron a routine of monthly peels to improve her skin’s overall textureand firmness—but she still felt that she wanted to look better. Soshe got a full face-lift. Her surgeon was terrific and made her lookcompletely natural—not forty—but a fresher, revitalized version ofherself. She is delighted. Employed in the highly competitive in-vestment banking industry, she says that she no longer worries that

126 L E V E L F O U R

if she loses her job, no one else will hire her. This thought inspiresher with a new self-confidence that actually radiates out of her.

But no matter how you perceive your appearance, or the ac-tual condition of your skin, your options abound if you wouldlike to make some kind of a change. You can still get good resultsfrom taking on the positive basic skin-care habits we outlined inchapters 3, 4 and 5 (Levels One, Two, and Three), as Irene did. Ifyou desire more of a change, you can supplement the basics within-office procedures such as peels, laser resurfacing, Botox, andfillers. Or you can make the decision to get some form of cosmeticsurgery. The most important and gratifying thing to remember isthat any change you make now will clearly be seen and impart youwith more beautiful and healthy-looking skin. Even a moderateimprovement in something that truly bothers you may have ahuge impact in your appearance.

For this reason, I recommend to everyone at Level Four (whohasn’t already) start with the least aggressive strategies and gradu-ally work your way up to more intensive ones—only if you wantto. While it may be difficult during these times of airbrushed per-fection, it is important that you decide for yourself what you wantand what you are willing to do to achieve it. Do not hold yourselfup to standards that don’t even exist in reality. It is also importantthat you don’t let yourself feel pressured by friends or the newsmedia to dive in all at once and dramatically alter your appear-ance if you are happy with it, or are on the fence about it, or look-ing to make a significant change. Remember, it is your face.

Martha, sixty-four, for example, was completely happy with theresults she was getting from fillers, Botox, and peels until she cameinto contact with one too many face-lifted acquaintances. Whileshe didn’t want to undergo the surgery, she somehow couldn’t helpfeeling that her appearance didn’t measure up to these otherwomen. After having a long heart-to-heart, we discovered that it

M A J O R C H A N G E S . . . O R N O T 127

was her hands, not her face, that were making her think she lookedtoo old. So we lasered off the brown spots, which made her handslook at least a decade younger. Now, she is much more content withher appearance and is no longer considering plastic surgery.

If you don’t want to deal with frequent injections and/orpeels, or if your main concern is sagging skin, in the end, it couldbe more time- and cost-effective to have some cosmetic surgery—especially if you want a dramatic change and are not satisfied bythe results of the less invasive procedures. It is worth noting, how-ever, that while cosmetic surgery does reset the clock in terms ofthe way your skin looks, it doesn’t resurrect the collagen-buildingmachine, shield you from free radicals or the sun, or exfoliate thedulling dead skin cells that can still accumulate. So good dailyskin-care habits will still be important. For this reason, womenwho’ve gotten face-lifts in their fifties, often get a second one intheir sixties. You also may still decide to get Botox to minimizethe lines caused by wear and tear or injectable fillers to plump upany remaining creases, which the face-lift failed to completelyeradicate.

Should you decide to get plastic surgery, it is of paramountimportance that you find a surgeon who has the proper qualifica-tion and is highly skilled and experienced in performing yourprocedure of choice. This may sound like a given, but the fact isthat anyone with a medical degree can legally practice plasticsurgery in the United States. In other words, you don’t have to bea plastic surgeon to perform a face-lift. Your doctor should beboard certified by the American Board of Plastic Surgery. Being amember of a surgical society, such as the American Society forAesthetic Plastic Surgery (ASAPS) and/or the American Societyof Plastic Surgeons (ASPS) indicates further qualifications and isproof that your doctor is board certified since both organizationsonly accept doctors who are. There are some organizations and


societies, however, where doctors without the appropriate experi-ence and training can buy their membership cerificates. I recom-mend that you check out any doctor you are considering with theAmerican Board of Plastic Surgery. In addition, your anesthesiol-ogist should be board certified by the American Board of Anesthe-siology (ABA).

To make sure you and your surgeon are on the same page, it’sa good idea to not only have several conversations with him aboutthe look you want but also to speak with, and preferably see, someof the patients who have had aesthetic surgery performed by him.Before-and-after photos can be compelling, but they are only partof the picture. Your doctor should also be completely fluent in ad-vanced and less invasive procedures such as endoscopic surgery,the minilift, and the subconjunctival blepharoplasty.

While some plastic surgeries and surgeons yield excellent re-sults (Alicia, for example), I’ve seen too many patients who haveface-lifts where they have been pulled so tight they look like theyare walking through wind tunnels. They may look younger butthey don’t look like themselves anymore. If your priority is to looknatural, you might discuss with your surgeon about going themoderate route (being pulled less tight) to preserve the natural ar-chitecture of your face. You can then plump up any remainingwrinkles with an injectible filler and use Botox to stop wear andtear. If you’d rather not be bothered by maintenance injectionsand want to look as young as possible, you may decide to go foran extreme face-lift. The point is, you have several choices in thetype of surgery performed and the end result you want.

Never before have there been so many ways to turn back thehands of time. While it may make it more difficult for us to de-cide which methods are appropriate for us, these new technolo-gies are bringing us closer than ever to looking vibrant and healthyat every stage in our lives.


The BasicsHere’s how to adjust the daily skin-care plans outlined in chapters3, 4, and 5 to better suit your specific needs. These additions andsubstitutions will help you to more precisely tailor your regimenand lifestyle habits to put you on the path to a gorgeous, radiantcomplexion. They will also enhance and extend the benefits ofany other treatment or procedure you may choose to do.

1 . T A K E C A R E O F Y O U R S E L F

Not to be an alarmist, but I personally think that it’s a good ideato get a physical twice a year instead of just once when you are inyour midfifties and beyond. The same goes for having your molesand general skin health checked by a dermatologist. Of course, ifyou are in overall good health and your physicians don’t advise it,then it’s probably not necessary. I do strongly believe, however,that it is important to treat any problem as it arises rather thanwaiting for it to become more serious. You know your body best.If you think there is something going on with you that merits avisit to your doctor, it most likely does. Making sure we are at thetop of our game is truly the most powerful weapon we have in ourantiaging arsenal. Taking prescription medications as directed,getting enough sleep, exercising regularly, and eating well are evenmore important now than they were just a few years ago. As wemature, our bodies’ reserves continue to diminish, making it evenmore difficult to fend off and bounce back from stresses like thesun, alcohol, a high-fat diet, smoking, and lack of sleep. Anythingyou do to protect your health not only can have profound effectson your well-being but also on your appearance.


Blanche, seventy-two, for example had always been sub-stantially overweight. Not happy with her appearance, she talkedabout getting a face-lift for years. But before she ever reached thisdecision she got bit by the fitness bug and embarked on a healthyeating and exercise plan. She lost her avoirdupois and in theprocess gained a healthy glow in her face and a great self-image.She is so much more energetic and confident now that she’s aban-doned all talk of plastic surgery of any kind.


Even if you made your regimen gentler just a few years ago, youstill might have to fine-tune it a bit more to avoid irritation. Asskin matures it continually becomes thinner and drier, which canmake it more reactive to products and procedures. If your facefeels dry, tight, itchy, has flakes, and/or stings, switch to an extramild cleanser and a heavier moisturizer for both day and night. Tohelp calibrate your personalized, nonirritating, yet still effective,skin-care regimen, read “Customizing Your Daily Regimen” (pages71–72).

3 . B O L S T E R Y O U R N A T U R A L D E F E N S E S

In addition to using antioxidant-based products mentioned in“Bolster Your Natural Defenses,” page 61, to fight free-radical at-tacks, it is also important to battle our own internal assailants. Aswe age, the natural enzymes in our skin that erode collagen out-pace the mechanisms that build and preserve it. Continually syn-thesizing collagen through all the measures previously outlined isa key way to combat these destructive forces. But now, especially,protecting the new collagen you create is an even more important


step. Both genistein and retinoids have been shown to block theenzymes that tear down collagen and, for this reason, are con-tained in the M.D. Skincare products. While genistein is com-pletely gentle for all skin types, prescription retinoids, in the formof Renova, can be drying and irritating, even though Renova hasa moisturizing base. You may start out with the lowest concentra-tion of Renova and see if you can tolerate it. You can gradually in-crease its strength if you aren’t irritated by it. If you are, dropdown to retinol, its nonprescription counterpart.

4 . C O N S I D E R V I T A M I N K — T O P I C A L L Y

You might have started to notice that you bruise more easily nowthan you used to and/or you have under-eye dark circles no mat-ter how much sleep you get. This is because our blood vessels arelined with collagen and as the quality and quantity of it dimin-ishes, they become more fragile and break more easily, which, forthe most part, is what causes the bruise or circles. Building colla-gen will help to strengthen them. Vitamin K (see chapter 8 formore details) can help to protect them from breaking in the firstplace and heal them once they do. To keep all your bases covered,I recommend applying creams that contain vitamin K topicallyand including it as part of a balanced diet.

5 . G E T Y O U R V I T A M I N B

Biotin, a B vitamin, has been shown to prevent and treat the dry,brittle hair and nails that can occur with age. Chapter 8, pages163–89, will outline biotin’s other benefits and how to incorpo-rate it into your diet.


6 . P A M P E R Y O U R S E L F

Never underestimate the power of doing things that make youfeel better. A massage, pedicure, or regular vacations not only willhelp you look your best but will also improve your mood andmake you more relaxed, which will have an even more profoundeffect on your appearance than the treatment itself. Rather thanBotox or collagen, Bea, seventy, gets her hair done every day asher main beauty boost. She says this little indulgence keeps herlooking and feeling more fabulous than any antiaging treatment.


While it may be more time-consuming and expensive, at thisphase in your skin care, taking it slow and steady will truly helpyou get the results you are looking for. It might be tempting to geta lot of Botox in entrenched forehead lines or extra filler to plumpup deep creases in the nasolabial folds. But as skin becomes thin-ner and more lax, you will get more natural-looking and attractiveresults by using a bit less of each treatment at one time, whichmay require doing it a bit more frequently. Treating specific re-gions of concern, rather than evaluating your face as a whole, maynow be a bit more problematic, but this can vary from person toperson. If one area becomes wrinkle free while the rest of the faceis going through the natural aging process, you might feel that itstands out or looks artificial in comparison.

Then again, you may not care. If you truly have a pet peeve,getting rid of it, and just that, might be all you ever want to do.


Annette, seventy-two, for example, was obsessed about the linesin her forehead and the furrows between her brows. In fact, whenshe looked in the mirror, they were the only things she saw. So shedecided to go for it. We used Botox optimally to give her the re-laxed, more youthful-looking forehead she had wanted but didnothing else for any of her other signs of aging. (See photo section,page 6.) She is completely happy with her appearance and isn’teven contemplating getting Botox or anything else, for that mat-ter, in any other part of her face.

Objectively speaking, there may be just one or two areas thatdo look older than the rest of your face. In fact, treating these fea-tures and just these features may be all you have to do to turnback the clock. Virginia, fifty-five, was stupendous looking—ge-netically blessed with a gorgeous, youthful complexion except forthe lines she had around her mouth; they literally looked at leastten years older than the rest of her face. Because they bothered herso much, she became very critical of her appearance and kept sug-gesting fairly aggressive full-face treatments, as well as Botox andsoft-tissue fillers—everywhere. I pointed out to her that the rest ofher face was fantastic, and there was absolutely no need to fixwhat wasn’t broken. Instead, we decided to go all out and justtackle her real issue—the lines around her mouth. We did deepCO2 laser resurfacing just in that area. She rode out all the oozing,weepiness, and redness. The procedure was a total success andthree years later, she is still delighted with the way she looks andhas stopped talking about doing anything unnecessary to her face.It also doesn’t hurt that most people are incredulous when shetells them she is fifty-five and not, in fact, in her mid-forties!

So whether you want to rejuvenate just one feature, several, oryour whole face, as always, the first step is to try the less aggressivestrategies already outlined. If you’ve progressed to the measures


outlined in Level Three (chapter 5), and still want more of achange, here are some more aggressive antiaging methods for youto consider:

G O I N G D E E P E R W I T H P E E L S , L A S E R S , A N D

D E R M A B R A S I O N T O S M O O T H O U T A N D T I G H T E N

L A X S K I N , W H I L E S P U R R I N G C O L L A G E N

Because of its recovery time and its possible complications, deepresurfacing is considered to be one of the big guns in the antiagingarsenal. It is performed either with a laser, a peel, or a dermabra-sion machine. Like their medium counterparts, deep laser andpeel resurfacing burn off damaged skin to erase many of the signsof time. Dermabrasion uses a mechanism that sands off the dam-aged surface. This controlled injury causes new collagen to formas the skin heals, making a face look smoother and more youthfullooking as a result. Depending on the amount of damage prior tothe procedure and the skin type, deep resurfacing can substan-tially reduce—even actually eliminate—lines in the upper lip,forehead, and crow’s-feet area. It is excellent for crinkling and willlighten sunspots. It is sometimes also used as a means to removeprecancerous growths called keratoses. You still may want Botoxto prevent wear and tear in certain areas, soft-tissue fillers indeeper indentations, sessions with a YAG laser to completely re-move brown spots, and light peels to help maintain your resultsand further stimulate collagen production. While it is not a magicbullet, deep resurfacing does treat several different issues simulta-neously and offers long-lasting results, making the face lookfresher and revitalized overall.

When considering deep resurfacing, it is important to keep inmind that, while it will have somewhat of an overall firming effect


on your face, it cannot tighten severe sagging, erase entrenchedforehead wrinkles, smooth out deep creases in the nasolabialfolds, or eliminate eye bags. If you crank up any of these treat-ments to the intensity where they could literally remove excesssagging skin, the risks would far outweigh the benefits. Sagging isbest tackled through surgical tightening. And in fact, deep resur-facing is often performed simultaneously with a face-lift to correctfine lines in the crow’s-feet and upper lip, since a face-lift only re-drapes and pulls drooping skin but doesn’t affect overall texture.

The degree of improvement depends on the strength of thepeel, laser, or dermabrasion machine; the depth they penetrate;and the extent of the damage before treatment. But the greater theintensity of the procedure, the greater its potential hazards. Thereis more than a 75 percent chance that deep resurfacing treatmentswill cause hyperpigmentation or hypopigmentation in peoplewith medium, olive, Asian, and darker skin tones. Scarring is an-other potential side effect. Frequently, these conditions are per-manent and cannot be concealed with makeup, especially in areasthat have been overlapped. Ultra fair-skinned people with lighteyes and blond hair are, for now, the best candidates for deepresurfacing. However, other skin tones can achieve good results ifthey don’t push for perfection and the doctor is conservative andextremely skilled at performing the procedure. Plus, some peopleprefer some slightly hypopigmented areas to lines and wrinkles. Itis a trade-off, so it’s up to you to decide which issues bother youthe most and which ones you can live with.

Because they are quite invasive with a lot of recovery time,these procedures are generally performed once in a lifetimethough, in some rare instances, they might be administered twiceseveral years apart. All of them are performed under local anes-thetic and may be combined with intravenous sedation to makeyou drowsy and calm. To prevent infection, your doctor will give


you prescriptions for an antibiotic and an antiviral medication tohelp prevent infection as well as cortisone to help prevent swellingand advise you when and for how long you should take each one.

The recovery time with all three of these treatments is sub-stantial though it does vary with skin type, your own natural heal-ing abilities, and the depth of the procedure. Typically, skin isoozing, weepy, bright red, and painful for one week afterward.For another one to three weeks, skin will remain a bright red thatmakeup typically cannot cover. After that, skin can stay unnatu-rally pink for up to two months, but you should be able to con-ceal it fairly well with makeup. I recommend you wait till anyredness completely recedes before using any products other thana gentle cleanser, sunscreen, and a fragrance-free and oil-freemoisturizer. It is also especially important to avoid sun exposure,which can cause hyperpigmentation in recently resurfaced skin,and to wear at least an SPF 30 whenever you are outside.

While the aftermath of a deep resurfacing treatment mayseem frightening enough to make you question someone’s sanity,none of my patients have ever regretted undergoing it eventhroughout the difficult healing process. Anna, fifty-two, for ex-ample, wanted to diminish the appearance of the lines above herupper lip and in the crow’s-feet area. Nonablative lasers, Botoxaround her eyes, and peels weren’t giving her completely satisfac-tory results. A plastic surgeon advised her that if she got a face-liftfor those areas, she also would need substantial work on her neckso it would be in sync with her newly lifted face. Since two surg-eries weren’t an attractive option for her, we discussed doing adeep CO2 laser treatment. Because of her skin type and the sensi-tivity of those two areas, we opted to do a full-face treatmentrather than treat each area separately so they wouldn’t stand outfrom the rest of her face due to hypopigmentation. While I wasfairly aggressive in treating her regions of concern, I could make


the laser less intense to treat her less damaged areas. After the chal-lenging healing process, her skin was radiant, more even toned,and less lined. Her skin looked fabulous, and she was delightedwith the results. The procedure did lighten her skin tone a bit butsince it was a global and not a regional change, she actually pre-ferred it to her original skin tone and merely lightened her hair toaccommodate the change. Seven years later, she is still extremelypleased.

Deep Laser Resurfacing

The most common laser used in deep resurfacing treatments isthe carbon dioxide (CO2) laser turned up higher than when usedin medium resurfacing. The laser is passed over the face to removethe skin’s surface and its accompanying lines, soft wrinkles, crin-kling, and sun damage. In the process, your skin’s fibroblasts arestimulated into producing collagen to “heal” the areas the laserhas removed.

Deep Chemical Peels

At the end of the day, peels aren’t that much different from laserresurfacing except that their destruction of the damaged skin ischemical rather than heat induced. The chemical solution elimi-nates a part of the sun damage and new collagen forms as part ofthe healing process. The type of acid, the lower its pH, and thelonger it is left on your skin will determine how dramatic the re-sults, how long the recovery, and the risk of side effects. The de-gree of improvement also depends on the extent of the damagebefore treatment.

For decades, phenol was the deep chemical peel of choice. But


with the advent of laser resurfacing, and the somewhat milder yetnearly as effective trichloroacetic acid (TCA), most dermatolo-gists and plastic surgeons no longer use it. The reason? In morecases than not, phenol peels significantly depigment the skin,leaving behind stark lines of demarcation at the edges of the facewhere the therapy ended. Phenol peels can also cause scarring andbe toxic to the body. It has been associated with cardiac arrhyth-mia, especially in people with prior heart conditions. Most der-matologists and plastic surgeons that perform deep peels now usea TCA solution at a stronger concentration than the one used fora medium peel since it has been shown to have fewer complica-tions and not carry the health risks of phenol.

Dermabrasion

Because it is the most aggressive and the least controllable of thethree options, dermabrasion isn’t as popular as it once was, but itis still used by some doctors. The procedure involves either a wirebrush or a burr containing diamond particles attached to a motor-ized handle (it looks like a dentist’s drill) that scrapes away theskin’s surface to make a wrinkle less visible. With dermabrasion,there seems to be the most opportunity for overlapping, which canlead to permanent linear scars and severe hypopigmentation. Butif you have very fair and severely damaged skin, it might be an ef-fective option for you.

Making a Choice

While all three resurfacing procedures have similar downtimesand nearly the same risks, I find the laser to be far more beneficialand less likely to cause complications than the other two methods


since it is more versatile and easier to control. For example, withthe medium laser, you can turn it up a bit higher to treat moredamaged areas and then gradually taper it back down for lessdamaged ones. With a peel and dermabrasion, your only optionis to rub or press harder in some areas than others, which will un-doubtedly increase your risk of scarring, hypopigmentation or hy-perpigmentation, and uneven results. It is important to discussthese concerns with your doctor so he can help you decide yourspecific needs and what will work the best for you. Whicheverprocedure you agree upon, make sure your doctor is extremely ex-perienced and adept at performing it.

Spot Treatment

If you are only troubled by one particular area of your face and ithas not responded to less invasive products and procedures, it ispossible to have a deep resurfacing treatment on just one region,such as the crow’s-feet or the lines around the mouth. This willdefinitely cut back on some of the downtime. The greatest riskwith regional resurfacing is that the treated area may look out ofsync with the rest of your face—either because it looks younger orbecause there is a noticeable change in skin pigmentation. It is,however, a plausible and highly effective solution in some cases.

F A C E - L I F T S F O R D E E P C R E A S E S I N T H E

N A S O L A B I A L F O L D S , G E N E R A L S A G G I N G

If you’ve tried all the less invasive measures outlined in chapters 3,4, and 5 and still want to make more of a change, it may be timefor you to consider some form of cosmetic surgery. The only wayto really eliminate and firm sagging skin, so far, is to remove someof it and pull the rest tighter. While a face-lift (technically known


as rhytidectomy) can’t stop time dead in its tracks, it can improvesome of the most visible signs of aging by eliminating excess fat,tightening muscles, and redistributing the skin of your face.

Performed either with local anesthesia and a sedative, or un-der general anesthesia, depending on patient and doctor prefer-ence, the surgery involves the surgeon first making an incisionabove the hairline at the temples, then extending it in a naturalline in front of the ear (or just inside the cartilage at the front ofthe ear), and continuing behind the earlobe to the lower scalp. Ifyou decide you’d also like some work done on your neck, a smallincision may also be made under the chin. In general, the surgeonseparates the skin from the fat and muscle below. Fat may betrimmed or suctioned from around the neck and chin to createmore definition. The surgeon then tightens the underlying mus-cle, pulls the skin back, and removes the excess.

Recovery time and postoperative pain vary. In general, ban-dages, if used, are typically removed after several days. Stitches areremoved in five to seven days. Your face may be pale, bruised, andpuffy for a few weeks; and your skin will feel somewhat tender andnumb. You may feel tired and not quite yourself for a week. Yourdoctor will give you specific guidelines about when you can returnto work, resume normal activities, and engage in vigorous ones.But expect to be at home resting for around ten days to two weeks.

You will have some permanent scars as a result of the opera-tion, but a skillful surgeon can conceal them in your hair or in thenatural creases of your face and/or ears, and they usually fadeover time. Complications from a face-lift may include hematoma(a collection of blood under the skin), nerve damage, infection,and reactions to the anesthesia.


Less of a Lift

If your concerns are mostly in the lower half of your face—e.g.,the nasolabial folds, jawline, and your cheeks—you may be a can-didate for a minilift, a procedure in which the skin and tissue areredraped only from the midface to the neck. Because the incisioncan be smaller and less of an area is being operated on, recoverytime and risks can be greatly reduced.

A new procedure utilizing one or two stitches buried belowthe skin to simply lift the face is pending FDA approval. This so-called Feather Lift may work well, especially to reduce the na-solabial fold, but only time will tell.

When seeking a dramatic change, a full face-lift or even aminilift aren’t your only options. You can ask the doctor to bemore moderate and pull less tightly and then use injectible fillersto plump up any remaining depressions. Employing this strategymay bring you closer to looking like a more youthful-looking you.If you look at pictures of yourself when you were younger, your facewasn’t just more taut; it was also fuller and plumper. If you decideto use a more permanent filler such as silicone or Artecoll, havethem administered after the surgery because if done before sur-gery, these fillers may protrude once the skin is pulled more tightlyover them.

Another procedure that lifts sagging cheeks and reduces theappearance of deep groves in the nasolabial folds is the Gore-Texcheek lift. In this type of lift, the doctor weaves Gore-Tex threadsunder the fat pads in the cheeks, then knots them, lifting the fatup and out. When gravity exerts its pull again, the ends of thethread can be pulled taut. Most experts agree that this procedureis best reserved for younger women in their forties and fifties whohave less sagging and laxity in their muscles.


While it may seem wildly premature to even consider a face-lift or any type of lifting procedure when you are not even fifty, insome cases, it may be an appropriate choice. Susan, from Florida,was an avid fan of outdoor water sports and of going up north toski. When she was thirty-eight, she realized that she was headingdown the same path as her mother with prematurely sagging skinand deep creases in the nasolabial folds that would only get morepronounced over time. Most people, in fact, typically thought shewas in her late forties. Much to the protestations of her friendsand family who thought she was “way too young” to undergo thisoperation, she went for it and got a “light” face-lift. She is nowforty-five and is being mistaken for thirty-five.

But even if you see yourself repeating your family patterns ofpremature aging, getting a face-lift when you are too young canlead to disappointing results. Joanne was a huge sun worshiper anddecided to get a face-lift in her forties because she felt she lookedmuch older than her peers. She was very unhappy with the re-sults, either because she was not an appropriate candidate for thesurgery or she was pulled too tightly. She came to me at sixty-seven because despite the face-lift, she had continued to show dra-matic signs of aging, the result of her continuing to sunbatheregularly. We did everything we could to improve her skin’s tex-ture and firmness, but we were not getting the results she wanted.She was terrified to get another face-lift but was severely unhappywith her appearance. I explained to her that she was probablymuch more of a candidate for the operation now than she was inher forties and that she should find a surgeon with a more natural-looking aesthetic. She did just that and is extremely happy withthe results of this second go-round.


Even Less of a Lift

Permanent Gore-Tex or silicone surgical implants in the cheeksand/or chin is another way to provide somewhat of a lift to sag-ging skin, but that’s not their main purpose. It’s actually to addvolume and definition to areas that you feel need augmentation—tweaking what your were born with, so to speak, rather than turn-ing back the clock (though some age-related changes can be helpedtoo). Implants do hold up soft tissue to some extent and providecontour to less defined areas, which can lead to a more youthfulappearance. But implants do not correct sagging or prevent itfrom occurring. In fact, many surgeons who are doing chin im-plant surgery perform a neck lift or lipectomy simultaneously tohelp create more definition.

Since these implants are permanent, it is far better to createhigher, more chiseled cheekbones or a stronger chin later ratherthan sooner. There’s no telling how the rest of your face will holdup around them, and if you decide you’d like to have any kind ofplastic surgery later on, they can pop out and look unnatural un-der newly tightened skin. Should you become unhappy with animplant, removing it requires another surgery, which can causescarring and other complications.

A surgical implant is imbedded immediately under the skinthrough a very small incision. Typically the procedure is per-formed under local anesthesia and intravenous sedation. One ofits main drawbacks is that all types of implants can be felt andoftentimes seen through the skin. Silicone rubber is said to lookand feel more natural than Gore-Tex, however. In addition, cheekimplant surgery can yield asymmetrical results and an implantcan shift up or down over time, both of which may require addi-tional surgery to correct the problem. There is also a risk of infec-


tion, which will necessitate the implant’s removal. If this is thecase, you and your surgeon will decide if it’s worthwhile to replaceit. My observation, overall, is that individuals are happy with theirimplants when the surgery is performed by a meticulous and skill-ful plastic surgeon.

S A G G I N G N E C K A N D J O W L S

Three things can actually cause a sagging neck: excess skin, excessfat, and/or lax muscles. If you are not getting the results that youwant from light peels, antiaging products, and Botox injections,there is a group of surgical procedures to get right to the heart ofyour specific problems. You can have cervicoplasty to remove theexcess skin, platysmaplasty to tighten or alter muscles, and/orlipectomy, basically neck liposuction to remove excess fat.

In plastysmaplasty surgery, the surgeon first makes incisionsunder your neck and behind your ears in order to have access tothe platysma muscle and tighten it. Permanent sutures may beused to hold it into place. Sometimes part of the muscle is re-moved. But, as discussed, Botox injections can be a satisfactory al-ternative to this particular procedure (pages 79–84).

If your concern is excess fat, your surgeon will make a smallincision below the chin and suction it out as with liposuction. Fortoo much skin, he will make similar incisions for a cervicoplasty:one behind each ear and one under the chin, trimming parts ofthe skin and lifting it into place. The anesthesia used will dependon both you and your doctor’s personal preferences, how muchwork you want done, and your comfort level.

Recovery time varies but generally you will be instructed towear a compression bandage for about a week. Swelling andbruising can last for several days. Sensations of tightness, burning,


pulling, tingling, or numbness can last for up to a few weeks.Most people can return to work in ten to fourteen days but willmost likely have to wait about a month to resume more vigorousactivities.

F O R E H E A D

If your forehead is your main area of concern, you might betempted to consider a forehead lift or brow lift—especially ifyou’ve been regularly incorporating the less aggressive remediesoutlined in chapters 3, 4, and 5 and are still not happy with theway it looks. But before you take the plunge, it is important tonote that a brow lift is considered to be one of the most painfuland invasive forms of plastic surgery with a high rate of patientdissatisfaction. In addition, lately, its longevity has also beencalled into question. Though more studies are required, it maynot be the permanent fix it was once thought to be. Many plasticsurgeons now actually prefer to administer Botox rather than toperform brow lifts. According to the American Society of PlasticSurgeons, from the year 2000 to 2003, the number of brow liftsperformed declined by 52 percent, while the number of Botox in-jections administered by plastic surgeons increased by 267 percent.

Should you decide you would like the permanence and lowerregular maintenance of forehead surgery versus quarterly Botoxinjections, it is important to discuss your expectations with yoursurgeon. Do you want to have a perfectly tight, smooth foreheadand risk looking unnatural, or are you willing to live with someimperfections in order to preserve a more natural look? A com-mon complaint with forehead lifts is that the brows get posi-tioned too high up leading to a permanently startled expression.

You should also address the possibility that a surgically cor-rected forehead may look out of sync with the rest of your face


since, in some cases, it will look more taut and less lined thanother areas. For this reason, forehead lifts are often performed inconjunction with a full face-lift—the idea being that this wayyour entire face appears smoother and more youthful, rather thanjust one region. This necessity for having additional surgery maybe the deal breaker for you—or you may decide to go for it all.Another possibility is that you decide that you are so bothered byyour forehead that you don’t care if it looks younger than the restof your face.

In a forehead lift, the muscles and tissues that cause the furrow-ing or drooping are removed or tightened to smooth the forehead,raise the eyebrows, and minimize frown lines. You should discussthe merits of having the procedure done endoscopically—when atube-shaped probe (called an endoscope) is inserted through threetiny incisions at the hairline to permit the surgeon to see and per-form the entire procedure. Typically endoscopic surgery involvesless postoperative swelling, bruising, scarring, and discomfort.Most forehead lifts are performed under local anesthesia, combinedwith a sedative, though depending on patience preference and theamount of surgery, in some cases general anesthesia is used.

Healing time varies from person to person but downtime mayinclude swelling in the forehead, cheeks, and eyes for about aweek along with numbness on the top of the scalp. As the nervesheal, the numbness is generally replaced by itching, which may lastfor as long as six months. Endoscopic forehead-surgery patientsusually experience less of the numbness and itching than classicforehead lift patients. Some of the hair around your incision mayfall out and may temporarily be a bit thinner, but normal growthusually resumes within a few weeks or months. Permanent hairloss is an extremely rare, though possible, complication.

Most patients are back to work in a week to ten days, withmost visible signs of the surgery fading completely after about


three weeks. You will probably be advised to limit or avoid vigor-ous physical activity for several weeks. Prolonged exposure to heator sun also should be limited for several months.

Permanent complications are rare and may include injury tothe nerves that control eyebrow movement on one or both sidesresulting in an inability to raise the eyebrows or wrinkle the fore-head. Formation of a broad, highly visible scar is also a rare com-plication, but it generally has to be surgically removed so that a newthinner scar grows in its place.

L I N E S A R O U N D T H E M O U T H A N D T H I N N I N G L I P S

Increasingly, I find more and more of my patients frustrated thatas they mature, their lips start to thin out, and the area abovetheir mouths becomes heavily lined. But even if the lines arefirmly entrenched, less aggressive, noninvasive treatments, suchas nonablative laser sessions, light peels, and a good solid skin-care regimen with proven antiaging ingredients, such as vitaminC, retinol, and exfoliating acids, can help to smooth them outand make them less visible. If you haven’t yet tried any of thesemeasures outlined in chapters 3, 4, and 5, embarking on themnow can make a difference and prevent more damage tomorrow.The next step might be to try an injectible filler to plump up thelines and add volume to your lips (see chapters 4 and 5 forspecifics). So far, the more permanent fillers such as silicone,Artecoll, and Radiance have not proven themselves to be satisfac-tory at either augmenting thinning lips or filling in the lines abovethem. Studies have shown that their results are uneven, bumpyand/or hard. It is also possible to have lips surgically augmentedwith implants; but in general, this procedure is rife with compli-cations such as infection, undue hardness, shifting, and a condi-tion where the implant literally pokes through the side of the


mouth (more common with Gore-Tex implants). For now, thetemporary fillers (Restylane, Perlane and Collagen) truly seem tooffer the best results.

For lines around the mouth, there are many more options. If,after peels, nonablative laser sessions, and fillers, you still wantmore of an improvement, you can try a medium laser resurfacingtreatment (done before you get a filler) outlined in chapter 5 or adeeper one for more substantial grooves (see page 135).

There are also a few minor tricks that can help return yoursmile to its former energetic and ebullient state. As we age, we of-ten get deep creases on the sides of the mouth that make it looklike it’s sloping downward all the time—almost like a perpetualfrown. I find that injecting a very small amount of Botox ¼ inchbelow the lower lip at the outer corners allows it to slope upwardin a more natural looking (read: happier-looking) curve. Again,being conservative is key. If too much Botox is used, it can resultin your not being able to smile properly or close your mouth allthe way. But if your doctor is skilled in the art of Botox correc-tion, it shouldn’t be a problem.

B A G G Y U P P E R A N D L O W E R E Y E L I D S

Both the upper and lower eyelids are fairly tricky areas to treat.The problems that usually arise there are due to excess or lax skinor the shape and thickness of the fat pads under the eyes. These is-sues, then, cannot be treated with Botox or fillers and cannot bedramatically helped with medium or deep resurfacing treatments.You can improve your eyelids’ appearance by building collagenstores and safeguarding your skin against free radicals as discussedin the first three levels.

One of the biggest issues for my patients with sagging eyelidsis that they feel that their eyes look smaller because their upper lid


droops over them. This is a common complaint, and there actu-ally is an easy, noninvasive and fast-acting solution for it. I havehad reasonably good results in “opening up” eyes by using a tinyamount of Botox. One shot is injected 1 to 2 mm below the lowerlid line, just in line with the pupil, to open up the lower lid, thuscreating a more open eye. The one caveat with this technique isthe doctor needs to be extremely precise in administering theBotox to avoid opening it up too much or you temporarily won’tbe able to close your eyes all the way.

Plastic surgery, on the other hand, is permanent. And thatsometimes can have its merits. If you’ve tried all the noninvasivestrategies outlined in the previous chapters and are still not happywith the appearance of your eyes, you may want to take theplunge and consider a blepharoplasty to remove fat along withexcess skin from the upper and lower eyelids. In general, the sur-gical community regards blepharoplasties as one of the most risk-free procedures that deliver the most satisfying results, thoughthey are not completely without complications. Blepharoplastiesare usually performed on an outpatient basis under local anesthe-sia along with oral or intravenous sedatives.

In a typical procedure, the surgeon makes incisions in thecreases of the upper lids and just below the lashes in the lower lids.The incisions may extend into the crow’s-feet at the outer cornersof your eyes. Working through these incisions, the surgeon sepa-rates the skin from underlying fatty tissue and muscle and removesexcess fat and trims sagging skin. The incisions are closed withvery fine sutures. Often, this procedure is combined with deeplaser resurfacing to remove fine lines at the same time. If you andyour surgeon decide that this is an appropriate course of actionfor you, be sure to discuss your risks of hypopigmentation and theother complications that can result from deep laser resurfacing(see above for more specifics).


Following the surgery, you will be instructed to keep yourhead elevated for several days and to use cold compresses to re-duce swelling and bruising, which can last anywhere from twoweeks to a month. Your eyes also may be dry, burn, itch, tear, besensitive to light, or have blurred vision for the first few weeks.Some people may not be able to close their eyes totally when theysleep, which in rare cases can be permanent. Another very rarecomplication, which can only be corrected with more surgery isectropion, when the lower lids pull downward. A more commonoccurrence is when too much fat is taken out from the lower lidresulting in a hollow, almost skeletal appearance under the eyes.Discussing these concerns with your surgeon can minimize therisks of them occurring as some are related to the degree of cor-rection you seek.

If you have under-eye puffiness without sagging and chooseto surgically eliminate it, you might be a good candidate for asubconjunctival blepharoplasty. This procedure is usually per-formed on younger patients with thicker, more elastic skin. Lessinvasive than a traditional blepharoplasty and with far less down-time, the surgeon makes just a tiny incision on the inside of theeyelid using a scalpel and then excises the excess fat causing thepuffiness. The area is then cauterized to stop the bleeding. Be-cause the procedure requires such a small incision and the bleed-ing is minimal, there is seldom, if any, scarring and only a tinyamount of bruising immediately afterward. The bruising gener-ally can be covered with makeup and subsides in a week or less.

Sometimes, eyelid surgery positively can affect other features,as well. Jean, sixty, for example, got her upper and lower eyelidsdone so she could better address the issue that was really bother-ing her—the lines and furrows in her forehead. Because her eye-lids drooped (which didn’t thrill her all that much either), I couldnever use Botox optimally to smooth her forehead because it


would have made her lids sag further. Instead of opting for thepainful and risky brow-lift surgery to make her happier with herforehead, she decided on the far less invasive and less chancy bleph-aroplasty surgery. Once her lids no longer sagged, we could useenough Botox to completely correct her forehead lines. Thesurgery, in effect, tackled two problems simultaneously and al-lowed her to take a less aggressive approach that still provided dra-matic and satisfying results.

Whichever route you choose to go—be it surgical, topical, in-office procedures, or a combination—now, more than ever, is thetime to make decisions for yourself. It can be trickier these days tobe happy with the way you look when other women your age lookyounger due to plastic surgery. But it is important to rememberthat while plastic surgery may turn back the clock, it may alteryour features so you just don’t quite look like yourself anymore,which may be a welcome change for many. Decide what you wantto look like and act upon it. Do you want to look your natural selfonly somewhat younger, less tired, and more refreshed? If so, thenantiaging products and in-office procedures are sufficient. If youwant to look much younger and accept the risk of looking differ-ent from your previous self, then plastic surgery may be your bestoption. Sometimes a combination of both options is the best ap-proach.

The most exciting part of being in Level Four? Any changeyou make will clearly be seen. There is so much you can do to getand/or maintain beautiful healthy-looking skin.


7Beauty Bonus Pointsy

1 4 S U R E F I R E L I F E S T Y L E H A B I T S F O R H E A L T H I E R A N D Y O U N G E R -

L O O K I N G S K I N

When it comes to our skin, maintaining a balanced dietand overall healthy lifestyle are guarantees. If you do,there is no question that you will look better than if

you don’t. Of course you can’t “be perfect” all the time. The goal,here, is to make deposits in your beauty bank by drinking enoughwater and getting enough sleep, among others, to outweigh thewithdrawals, such as smoking, drinking to excess, and sunbathing.Racking up beauty bonus points will also help you to better with-stand an occasional splurge and to make up for some of the fac-tors that are beyond your control; for example, your past sunexposure and lifestyle habits, and your genetics. Here, in no par-ticular order, are the healthy habits that I have found in all myyears of practice to be the most crucial to the health and appear-ance of my patient’s skin.

1 . G E T E N O U G H S L E E P

Truly this is easier said than done for those of us who not onlynever seem to have sufficient hours in the day but also have enoughstress to keep us wide awake when we finally do crawl into bed.Think of how you look and feel when you come home from a va-cation where you finally managed to “catch up.” Imagine lookingand feeling that way all the time! The reason chronic lack of sleep(and to a lesser extent occasional sleepless nights) affects us sonegatively is because the body responds to it by setting off ourfight-or-flight response because it sees our intense fatigue as a mildstate of emergency. The production of the stress hormones corti-sol and epinepherine (a.k.a. adrenaline) are triggered, which thenprompts the body to divert a disproportionate amount of bloodflow, oxygen, and nutrients away from our external organ (i.e.,the skin) to the major internal ones, such as the heart, brain, andkidneys. When the skin is getting less than optimum fuel, it canbecome dull and pale with dark under-eye circles. Lack of sleepcan be so stressful that it actually causes our bodies, including ourskin, to generate free radicals.

You might also find that not getting your beauty sleep resultsin lines and wrinkles looking more firmly entrenched. The rea-son? Our sympathetic nervous system involuntarily contracts ourmuscles in response to the overall stress the body is experiencing.Think about how tight your neck and shoulders can get when youare really stressed out. In the case of our faces, when our musclesare contracted, such as when we clench our jaws or furrow ourforeheads, our problem areas become more pronounced.

154 B E A U T Y B O N U S P O I N T S

2 . K I C K T H E H A B I T

Smoking is like a triple whammy to our overall health and to ourskin. First off, tar triggers free radicals, which can cause canceras well as break down collagen. Secondly, nicotine disrupts sleepbecause it is a stimulant. Ever notice how cigarettes can makeyou feel hyper? It’s the nicotine that makes our heart race, whichis also what ultimately contributes to heart disease. Nicotinealso mimics the effects that stress hormones have on the bodyby sending it into a flight-or-fight mode. Lastly, smoking agesthe skin around the mouth because, next to the lungs, themouth is the prime recipient of the toxins in secondhand smoke.Meanwhile, regularly pursing the lips to take a puff causes enoughwear and tear to create smoker’s lines—pleats around the lips thateventually become visible even when you’re not smoking. (Seephoto section, page 3.)

3 . S W I T C H T O A S A T I N P I L L O W C A S E

While it may make some people snore, sleeping on our backs (some-thing I can’t do) is actually the best position to help preserve ayouthful-looking complexion. In fact, stomach and side sleepers(especially those who favor the same side every night) actually runthe risk of getting lines as a result of their nocturnal habits. Thisis because persistently pressing our faces into a pillow causes traumato the skin. Over time, this trauma, aggravated by the friction ofa cotton pillowcase, can create permanent creases as our collagenbreaks down. In addition, the weight of our own faces impairs cir-culation to the part we have pressed into the pillow, which com-promises the skin’s regenerative abilities. If you cannot sleep onyour back, which takes the pressure completely off the face, trycovering your pillow with a satin pillowcase to minimize friction.

1 4 S U R E F I R E L I F E S T Y L E H A B I T S 155

While there still can be a slight amount of abrasion, the skin willslide more easily over satin than cotton. The women in the 1950swho slept on satin pillowcases to protect their hairdos were reallyonto something!

4 . E X E R C I S E R E G U L A R L Y

Not working out doesn’t just affect our waistlines, it can also showup in our faces. The American Heart Association recommends aminimum of thirty to sixty minutes of vigorous activity (if you arefit), at 50 to 70 percent of your maximum heart rate on most daysof the week if you want to exceed a moderate level of fitness,which has been shown to have increased health benefits. Butmoderate-level activities often will help lower your health risks tosome extent. When our cardiovascular system is functioning opti-mally we have proper circulation, which ensures the optimumflow of blood and nutrients to the skin. Working out just beforean important event is also one of the beauty secrets of those whoregularly walk the red carpet. Because exercising (cardio in partic-ular) revs up the circulatory system, it not only imparts the facewith a radiant glow but it also mobilizes any trapped fluids sopuffy areas usually deflate dramatically and remain that way for atleast several hours afterward. Sweating also helps to release anywater that your body may be unnecessarily retaining. Just don’toverdo high impact, skin-damaging aerobic activities.

5 . G I V E T H O S E K N E E S A R E S T

High impact exercise, especially running, may result in fabulouslegs, but it can negatively impact the skin. It has been my obser-vation that most die-hard runners have premature lines, wrinkles,


and sagging. I’m fairly certain that their damaged skin is not justdue to the sun but also to the constant pounding their bodies aresubjected to. Newton’s third law of physics explains it best: “Forevery action, there is an equal opposite reaction.” This means thatif a 130-pound woman’s foot strikes a surface, the force of 130pounds bounces back off the ground and up into her body. I be-lieve this jostling not only can damage joints but also can causecollagen breakdown. If you are a passionate runner and are con-cerned about your skin, try alternating your runs with lower im-pact forms of exercise, such as walking, the Stairmaster, bike, orElliptical Cross Trainer. While it may be a four-letter word tomarathoners, some running coaches actually counsel their clientsto walk one minute for every mile they run to save their jointsand, believe it or not, help improve their time. And I have manypatients who have switched from running to fast walking andlove it.

6 . L I M I T E X P O S U R E T O E X T R E M E T E M P E R A T U R E S

The signs posted outside steam rooms, saunas, and Jacuzzis rec-ommend that you spend no longer than ten to twenty minutesbasking in their warmth. This guideline is given to prevent thecomplications that could arise from their affect on blood pressureor other medical conditions. But keeping this time limit in mindcan also have positive effects on skin. Prolonged exposure to ex-cessive heat can break down our collagen and elastin and causebroken capillaries. In addition, extremely high temperatures can alsospeed up the breakdown of injectible antiaging fillers such as colla-gen, Perlane, and Restylane, as well as reduce the longevity of Botox.

Excessive cold, on the other hand, can also cause broken cap-illaries. When we are freezing, our body attempts to conserve heat


internally by constricting the blood vessels on the skin’s surface sothat it becomes shortchanged of the nutrients, blood flow, andoxygen it needs. In response to this stress, our skin produces morevessels in an attempt to supply it with more blood flow. If you arean avid skier, prone to broken capillaries, and concerned aboutyour skin, you can help prevent further damage by wrapping ascarf around your face or wearing a ski mask when temperaturesare especially frigid.

7 . M A I N T A I N A S T A B L E W E I G H T

“At some point in your life, you have to choose between your faceand your rear end,” is a parable frequently printed in fashionmagazines. And it’s actually true. In my experience, people whohave repeatedly gained and lost substantial amounts of weightover their lifetime, or lose more than 5 percent from a healthybody weight beyond middle age, will most likely look older thanthose who haven’t. Weight gain of any kind stretches the skin,which stresses the collagen and elastin fibers. As we age, our skinhas less of an ability to snap back into shape when we lose theweight that caused it to expand in the first place. I’ve had patientsin their fifties whose faces looked great until they lost a significantamount of weight. Then, all of a sudden they looked like theyneeded a face-lift because their skin couldn’t recoil back farenough. It’s better for our faces to lose weight in our twenties andthirties while our skin is still elastic. After that, it may not be a badidea to lose weight gradually while evaluating the effects it is hav-ing on your face. It’s generally a trade-off, but it’s up to you, notwhat the media or your peers dictate, to decide which mattersmore to you. While you may want to lose twenty pounds to fitback into a favorite article of clothing, your face might look moreyouthful if you limit your weight loss to ten pounds. Similarly, you


might prefer having an extra svelte figure to a fuller face. Both areattractive options.

8 . T R Y T O K E E P A R E G U L A R S C H E D U L E

W H E N T R A V E L I N G

Our body has its own natural, or circadian, rhythm for its wake-sleep cycles. It typically produces our highest amount of the regu-latory hormone cortisol, which gives us energy and alertness, at8:00 A.M. and the lowest amount at 4:00 P.M. This dip in cortisolis why we often feel lethargic in the afternoon and start to crave acandy bar or a cup of coffee to give us a shot of energy. Jet lag dis-rupts this natural rhythm so that we end up producing cortisolwhen we don’t need it. When our body is in this state, the stresshormones become activated and produce the same effects as whenwe are in fight-or-flight mode. I find that one way to counteractjet lag is to make small adjustments geared to the time zone youare in. For example, when I fly from New York to L.A., I try tokeep myself awake till 10:00 P.M. L.A. time (1:00 A.M. New Yorktime) and then I am generally able to sleep till 6: 00 A.M. (9:00A.M. New York time). Every night thereafter, I seem to be able tostay awake a little bit longer and sleep a little bit later. But youknow your body best. So you may even have your own jet lagremedies. The important thing here is to try and get enough sleepwhenever you can, wherever you are.

9 . T R A V E L W I T H Y O U R O W N W A T E R

It’s not only the water that we drink that can affect our skin, it’salso the water with which we wash our faces. I have patients whotravel and return from their trips with blemishes, rosacea, exces-sive shine, or irritation that they didn’t have before. I believe this


is because the tap water in their hotels has different minerals fromthe water coming out of the faucets in their homes. If skin is notaccustomed to certain minerals, they may cause adverse reactions.I have found that the best way to combat this travel-related skinproblem is to simply pack an Evian mister or a spray bottle filledwith tap water from your home when you travel. Use either oneto rinse off your face after you cleanse with the local water.

1 0 . A V O I D A L C O H O L - B A S E D S K I N - C A R E

P R O D U C T S

Applying alcohol topically can dehydrate skin, break blood ves-sels, exacerbate rosacea and eczema, plus trap skin in a vicious cy-cle. Because it dries out skin, alcohol can prod it to produce moreoil to help lubricate it, which may then lead you to use even moreof the alcohol-based toner. Eventually the skin becomes over-stripped so the alcohol-based product has the ability to penetratemore deeply than it is supposed to, which can cause the type of ir-ritation that can lead to broken capillaries.

If you like to use a toner—whether to control excess shine, re-move cleansing residue, or exfoliate—switch to one that is witchhazel–based, which does all of the above without stripping.

1 1 . R E M O V E M A K E U P B E F O R E G O I N G T O B E D

Hitting the sheets “made up” can clog pores and oil glands, whichis almost a surefire ticket to blemishes and irritations. In addition,once the makeup becomes impacted in pores, it can actuallystretch them out and make them appear larger. Once makeup andother pore-clogging gunk is removed, pores usually shrink back totheir original size. But as we mature and our collagen production


declines, stretched out pores no longer completely snap back intoshape and so become permanently enlarged.

1 2 . B E G E N T L E

Exfoliating with rough, grainy, scrubs, or scouring skin with yourfingernails while cleansing can cause irritation, and broken bloodvessels. It will also aggravate acne, rosacea, eczema, and seborrheicdermatitis. If you prefer to use an exfoliating scrub, look for onesthat incorporate smooth, round, polyethylene beads versus prod-ucts with rough, jagged nuts, seeds, husks, kernels, or pits.

1 3 . W E A R S U N G L A S S E S

Because the skin under and around our eyes is especially thin, anydamage to this region shows up faster than anywhere else on theface and is particularly noticeable. Sunglasses serve as a physicalbarrier to block out the ultraviolet rays and so help to preventthe signs of premature aging. Wearing sunglasses also helps stopus from squinting, which causes wear and tear around the eyes andin between brows. When selecting a pair of sunglasses, thinkSUNGLASSES—Big, round, full coverage glasses that sit firmlyand high enough on the bridge of the nose so there is minimalspace between your face and the frames for the sun to penetrate.Jackie O got it right, and she was not only a fashion icon but shealso had lovely skin. And make sure your big round fashionablelenses have been treated with a broad-spectrum (UVA/UVB) pro-tective coating.


1 4 . W E A R S U N S C R E E N A N D L O T S O F I T

Safeguarding your skin against the sun is the single most impor-tant thing you can do for your skin’s health and appearance. Andif you are using products that increase your photosensitivity, suchas Renova, it’s doubly important. It’s so important, in fact, thateven though it’s been said millions and millions of times, it’s al-ways worth repeating: Wear sunscreen and lots of it. An SPF 30 isoptimal.


8YT H E R E C I P E F O R G O R G E O U S S K I N

We may not be able to control our genetics or thelifestyle habits we had in the past, but we can moni-tor what we eat; and the payoffs of a healthy diet are

amazing. Eating well is one of the easiest, least expensive, andguaranteed ways to achieve and maintain radiant and beautifulskin—not to mention what it will do for the rest of your body. Iconsider it another health and beauty bonus point. For this chap-ter, I enlisted my friend Caren Feingold, RD, a New York Citynutritionist in private practice to compile a list of some of themost important nutrients for skin (and your overall health, by theway). To my mind, there are six rules of thumb that will help putyou on the path to amazing-looking skin:

1 . T H I N K H E A L T H Y H E A R T , H E A L T H Y S K I N

All the foods we’ve been told to eat and to avoid for the preven-tion of heart disease can also benefit our skin. When the arteriesbecome clogged from an excess of fat in our diets, all the tissues ofthe body, including the skin, receive less blood, oxygen, and nu-trients. Highly saturated fats also generate more free radicals. Theend result is that all parts of the body, including the skin, incurmore damage.

2 . S T O C K U P O N A N T I O X I D A N T S

Any foods with antioxidants, such as vitamins C and E, lycopene,green tea extract, etc., are considered to have heart-healthy andeven cancer-fighting benefits. Bonus? Many of them destroy thefree radicals that eat away at our skin’s building blocks, collagenand elastin. Vitamin C actually stimulates collagen production. Adiet rich in bright multicolored vegetables and fruits will go far toensure you are getting enough of these great defenders on a dailybasis.

3 . E A T E V E R Y T H I N G — I N M O D E R A T I O N ,

O F C O U R S E

Diets that advise you to cut out entire food groups will makeyou miss out on the nutrients necessary for overall health andfabulous-looking skin. For example, extremely low-carbohydrateplans limit fruits and some vegetables—the main sources of antiox-idants. Very low-fat diets may be missing essential fatty acids,which the body and skin require to absorb the fat-soluble vita-mins, maintain lubrication/moisturization, and repair tissue. Dietsmust contain protein—one of the essential building blocks for


healthy hair, skin, and nails. Calcium, which may not be directlyinvolved with the skin, is extremely important for healthy boneand teeth.

4 . C H E W A N D S W A L L O W

It’s better to try to get your nutrients from food rather than fromsupplements. An overwhelming majority of the nutritional com-munity is now realizing that it’s not only the vitamin or mineralin a food that is beneficial, but also the other aspects of the fooditself (referred to as the bioavailability) that work synergisticallyto enhance the vitamin’s performance. In addition, while it’s ex-tremely difficult to overdose on nutrients from foods, it is possi-ble to have an excessive amount of a vitamin or mineral if youtake supplements. It is especially important to avoid an excess offat-soluble vitamins such as A, E, and D, niacin, B6, and pan-tothenic acid, and minerals such as copper, magnesium, and zinc.An excessive amount of some of these supplements can be haz-ardous to our health.

Caren suggests that if you eat a lot of fortified foods, such ascereals, energy bars, juices, and shakes, check their labels for theamounts of all nutrients before you start taking a vitamin or min-eral supplement.

5 . D R I N K W A T E R

Not drinking enough water causes dehydration of both the skinand body. This makes our complexion look less firm, radiant, andplump. In my experience, our individual needs for water vary,based on our diet, salt intake, exercise habits, the amount we per-spire, and if we live in a hot climate. Our thirst is our body’s wayof signaling that it needs more water. So let thirst be your guide as

T H E R E C I P E F O R G O R G E O U S S K I N 165

to how much water you, specifically, need. If you drink enoughwater to satisfy your thirst, it will keep your body sufficiently hy-drated. If you drink more than that, it probably won’t hurt youbut it won’t make your skin look any better because we just elim-inate the excess.

6 . D R I N K A L C O H O L M O D E R A T E L Y

While some research indicates that moderate amounts of liquorcan benefit the heart, excessive drinking just isn’t healthy. We’ve allhad too much to drink and awakened the next morning lookingand feeling bad. Here’s why. Alcohol is a diuretic, so it dehydratesboth our skin and our bodies—one of the reasons for that pound-ing headache the morning after. Dehydrated skin loses its plump,firm, and dewy appearance so it may appear drawn, lax, and morelined than usual. We might also appear puffier, since alcohol is avasodilator—meaning it opens blood vessels. So while we are try-ing to sleep off the effects of too many martinis, the alcohol-dilated capillaries leak circulatory fluids into our tissues, causingthe skin to swell. The good news? Rehydration (drinking water) re-vives skin and helps that headache. And as we start moving aroundthroughout the day, our blood flow becomes normalized and ourpuffiness, along with dark circles will fade.

Too many cocktails disrupt sleep and stimulate free-radicalproduction. Our bodies have to divert blood flow, oxygen, andnutrients away from the skin to our vital organs to help processthe alcohol. This action has an additional impact on skin becausewhen skin has poor circulation, it actually creates extra blood ves-sels to try to get what it needs. This is the reason many alcoholicshave so-called gin blossoms—a profusion of broken capillaries onthe nose. Last, but not least, alcohol is also taxing to the liver,which is the organ that helps us eliminate toxins. Sallowness is a


direct result of a liver having difficulty with its detoxifying duties.The more we drink, the more it stresses our liver. Eventually, itwill have less of an ability to eliminate toxins and free radicalsfrom the body and pallor can result. In addition, alcohol actuallypromotes the growth of “bad collagen,” or scar tissue, in both theskin and liver. Cirrhosis is the result of scar tissue developing inthe liver, due to the constant onslaught of free radicals.

6 . C U T D O W N O N C A F F E I N E

Believe it or not, caffeine actually affects the body in many of thesame ways alcohol does. Excess caffeine can cause dehydration,disrupt sleep, trigger stress hormones, and because it engorgesveins, it can also cause broken capillaries. We know when we’vehad too much! It can make us jittery, elevate our heart rate, andcause insomnia. Another surefire sign of too much caffeine is darkunder-eye circles. Our skin and health would benefit greatly if welimited our caffeine consumption to only one or two cups of cof-fee a day.

Nutrition for Your SkinWhile new ingredients that can beautify your skin and benefityour overall health are being discovered on almost a daily basis,here are some of the important tried and true components of abeauty diet. I’ve also included a few new ones that have excitingresearch behind them that should be considered daily essentials.


A M I N O A C I D S

What they are: The building blocks of all proteins in our tissues,including skin. There are nine essential amino acids that we needto get from food; the body can make the other eleven.

Where you can find them: Meat, fish, poultry, eggs, dairy products,and beans.

USRDA: None.

A N T H O C Y A N I N S

What they are: Potent antioxidants found in a water-soluble pig-ment that gives plants brilliant colors ranging from pink throughscarlet, purple, and blue.

What they do: Anthocyanins are considered to be helpful in treat-ing and preventing certain types of cancers and heart disease.They also have been found to improve visual acuity, treat circula-tory disorders, help diabetes and ulcers, and have antiviral and an-timicrobial abilities. Promotes skin health.

Where you can find them: Blueberries, cherries, elderberries, grapes,black currents, and hibiscus flowers.

USRDA: None yet established.

B I O F L A V A N O I D S

What they are: Bioflavanoids are another type of plant pigmentthat keeps fruits and vegetables brightly colored because their po-tent antioxidant powers prevent the oxidization that turns fruits


and vegetables brown. They continue to act as powerful antioxi-dants in the body. This is one of the reasons multicolored saladsand a varied diet of fresh fruits and vegetables are so highly rec-ommended for maintaining optimal health.

What they do: Bioflavanoids are considered by some scientific cir-cles to be more powerful free radical scavengers than vitamins Cand E. They are also essential for the stability and absorption ofantioxidant vitamin C, one of the key collagen-building catalysts.As with other antioxidants, a high bioflavanoid intake is related toa lower risk of heart attack, cardiovascular disease, and someforms of cancer. Sometimes called flavones or vitamin P becauseof their effect on the permeability (the rate at which somethingpasses through the cell membranes) of capillaries. Bioflavanoidsalso have been shown to help heal wounds and support a healthyimmune system. They also have antiviral, anti-inflammatory, andantiallergy properties.

Where you can find them: While precise amounts of bioflavanoids infoods have not yet been determined, this type of antioxidant isabundant in apricots, cherries, cantaloupe, papaya, grape seedextract, pine bark extract, citrus fruits, black tea, onions, parsley,legumes, red wine, red grapes, red cabbage, buckwheat, and allblue and purple berries.


C O E N Z Y M E Q - 1 0 ( U B I Q U I N O N E , U B I Q U I N O L E )

What it is: Coenzyme Q-10 is a compound that is made naturallyin our bodies and is used by our cells to produce the energy theyneed for their growth and maintenance. Coenzyme Q-10 is be-lieved to be essential for generating up to 95 percent of the total


energy our bodies require in order to function at optimum levels.It is also an antioxidant with actions very similar to those of vita-min E. Coenzyme Q-10 also stimulates our circulation and im-mune systems. It is believed to have a powerful antiaging effect, aswell.

Where you can find it: Mackerel, salmon, sardines, beef, peanuts,and spinach.

USRDA: None

C O P P E R

What it does: When taken internally, this mineral has been shownto be a significant factor in both hemoglobin and collagen forma-tion.

Where you can find it: Organ meats, seafood, nuts, seeds, wheatbran cereals, whole grain products, and cocoa products.

USRDA: 900 mcg per day for men and women; 1800 for vegetari-ans because the body needs a certain amount of zinc in order toabsorb copper, and many vegetarians are zinc deficient; zinc is lessreadily absorbed from nonanimal sources. But the exact oppositeis also true—an excess amount of zinc can interfere with copperabsorption and cause a deficiency.

How to meet it: The exact copper content of foods has not been pre-cisely calculated yet, but if you eat a well-balanced diet of mostlynonprocessed foods, you should have no problem meeting theUSRDA.


E S S E N T I A L F A T T Y A C I D S

What they are: Linolenic/omega-3 fatty acids: (includes alpha-linolenic acids and eicosapentaenoic acid (EPA) and linoleic acid/omega-6 fatty acids: (includes linoleic and gamma-linolenicacids). These two polyunsaturated fatty acids are crucial to ourbody’s basic functioning. Since they cannot be made from othersubstances within the body or from each other, we have to getthem from food or supplements.

What they do: Both are components of hormone-like substancesthat regulate a variety of our bodily functions, including ourblood pressure, blood clot formation, and immune response.They are also part of the structure of cell membranes and are es-sential for rebuilding cells as well as reproducing new ones. Somestudies have shown that essential fatty acids (EFAs) also maintainand improve the health of our hair and skin and help to easeeczema and psoriasis. EFAs are also thought to lower cholesteroland triglyceride levels and thus are beneficial to treating and pre-venting cardiovascular disease.

Where you can find them: Linoleic acid/omega-6 fatty acids (in-cludes linoleic and gamma-linolenic acids) are in oils such asgrape seed, evening primrose, sesame, and soybean; seeds; nuts;legumes; and whole grain products. Linolenic/Omega-3 fattyacids (includes alpha-linolenic acids and eicosapentaenoic acid(EPA) are in fresh deepwater fish, including salmon, mackerel,herring, sardines; fish oil; and some vegetable oils, such as canola,flaxseed, and walnut oils.

NOTE: Cooking with these oils actually destroys their EFA contentand creates free radicals. It’s best to consume them as uncooked


liquids (as in salad dressing) or in supplements. It is far healthierto cook foods in olive, safflower, and corn oils.

USRDA: While there is no USRDA for EFAs, experts recommendthat they represent 10 to 20 percent of our total daily caloric in-take. Many nutritionists offer the following advice to help usmeet our EFA needs: Eat fish two to three times per week, as wellas a small amount of vegetable oils, to obtain the right balance be-tween omega-6 and omega-3 intakes. The ratio of omega-3 toomega-6 should be about 1 to 4. This ratio is believed by some tobe the key to their effectiveness.

G R E E N T E A

What it is: A beverage widely consumed in Japan, China, and otherAsian nations that has recently gained more widespread popular-ity in the West. Its main claim to fame is that it is rich in chemi-cals known as polyphenols (also found in white tea), which havepotent antioxidant properties.

What it does: Many researchers believe green tea may help to pre-vent some cancers because of its high antioxidant content. Thistheory is largely due to the fact that people in Asian countries whodrink green tea seem to have fewer incidences of certain types ofcancer, such as prostate, stomach, and esophageal. Also, green teacontains epigallocatechin-3-gallate (EGCG), a compound that isbelieved to block production of the enzyme required for cancercells to grow. EGCG may work by suppressing the formation ofblood vessels, a process called angiogenesis, thereby cutting offthe supply of blood to cancer cells. But while animal studies havebeen promising, results from human studies have been mixed.Stay tuned.


Meanwhile, favorable research has demonstrated that greentea extract not only can fight both environmental and metabolicfree radicals but that it also repairs DNA. Damaged DNA pro-motes aging, reduces your defenses against free radicals, dimin-ishes your cells’ regenerative ability, and can even result in skincancer.

Green tea may also have numerous other health benefits.Herbalists prescribe it for stomach problems, to reduce tooth de-cay, to reduce high blood pressure and cholesterol levels, and tohelp promote healthy circulation by helping shrink blockages ofthe blood vessels in the heart that can lead to heart attacks.

Where you can find it: In green tea leaves and tea bags.

USRDA: None. But in Asian countries people generally drink threecups a day or more.

I R O N

What it does: This mineral is a key component of hemoglobin inour blood and myoglobin (a red protein that comprises our mus-cles), both of which supply oxygen to cells. A deficiency in ironcan lead to anemia, which can cause unduly pale skin, weakness,headaches, reduced resistance to infection, decreased tolerance tocold, and poor circulation, which can rob your skin of the oxygenand nutrients it needs to look its best.

Where you can find it: Red meat, fish, poultry, shellfish, eggs,legumes, and dried fruits.

USRDA: 18 mg per day for menstruating women, 8 mg per day fornonmenstruating women and men. Vegetarians often don’t incor-porate enough iron into their diets even unwittingly since the


body doesn’t as easily absorb plant sources of iron. But non-vegetarians should try and eat both animal and plant-basedsources of iron for a healthier, better-rounded diet.

How to meet it: ¾ cup of breaded and fried clams, 3.0 mg; 3 oz.dark meat turkey, 2 mg; 3 oz. chicken breast, 1mg; 3 oz. beef ten-derloin, 3 mg; 3 oz. roasted white meat turkey, 1.2 mg; 3 oz. bluefin tuna, 1.1mg; ¾ cup 100 percent fortified cereal, 18mg; 1 cupcooked lentils, 6 mg; ½ cup cooked spinach, 3.2 mg; 1 cupcooked kidney beans, 5.2 mg; ½ cup firm tofu, 1.8 mg.

L Y C O P E N E

What it is: An organic chemical compound that gives yellow, red,or orange plants their color (caretenoid) and is loaded with an-tioxidants.

What it does: Major studies have found that it prevents the oxida-tion of low-density lipoprotein (LDL) cholesterol. High LDL ox-idation is associated with an increased risk of atherosclerosis andcoronary heart disease. Ongoing research suggests that lycopenemay reduce the risk of prostate cancer as well as cancers of thelung, bladder, cervix, and skin. Other major studies have shownthat lycopene is extremely potent at fending off environmentalfree radicals and so helps to prevent collagen break down. Ly-copene may also diminish the damage of free radicals causedspecificially from sun. The scientific and medical communitiesare fairly convinced that the more lycopene is researched, themore healing powers it will turn out to have.

Where you can find it: Fresh tomatoes, tomato sauce, tomato andtomato-based vegetable juices, tomato soup, tomato ketchup,


tomato paste, chili sauce, watermelon, pink grapefruit, guava,apricots, and red papaya.

IMPORTANT NOTE: Research shows that our bodies absorb lycopene intomatoes more efficiently if it is processed into tomato juice,sauce, paste, or ketchup.

USRDA: None. But major studies have shown that a daily con-sumption of at least 40 mg of lycopene can help you realize itsheart healthy and LDL- reducing benefits.

How to meet it: ½ cup spaghetti sauce, 28.7 mg; 1tbsp tomatoketchup, 2.7 mg; 2tbsp tomato paste, 13.8 mg; 1 slice water-melon, 14.7 mg; ½ pink grapefruit, 4.9 mg; 1 raw tomato, 3.7 mg.

M A G N E S I U M

What it does: This mineral activates all our enzymatic systems,which are the catalysts for all our bodily functions. It plays a rolein our nerve and muscle functions, is a key component of bonegrowth, and directly affects our body’s ability to metabolize cal-cium, potassium, and vitamin D. Because magnesium is necessaryfor the release of cellular energy in all of our body’s soft tissues, ithas a direct effect on the health of our skin. It also has been foundto improve circulation, which also favorably impacts skin. Recentpromising studies also have shown that magnesium supplementsenable heart disease patients to exercise for longer periods of time.It appears to protect their hearts from the stress of working out.

Where you can find it: Green leafy vegetables; unpolished grains,such as brown rice, wheat germ, and wheat bran; nuts, includingalmonds and peanuts; meat; milk.


USRDA: 320 mg per day for women; 420 mg per day for men.

How to meet it: 1 oz. of sunflower seeds, 100 mg; 1 oz. almonds,85 mg; 1 oz. cashews, 75 mg; 1 oz. wheat germ, 70 mg; 1 oz.Brazil nuts, 65 mg; 1 oz. dark chocolate, 35 mg; ½ cup cookedspinach, Swiss chard, or cooked beans, 60 to 80 mg; 3 oz. of mostkinds of fish, 50–90 mg.

P . E M B L I C A

What it is: An herb derived from the bark, leaves, flowers, androots of the Phyllanthus emblica tree. It is used in seventeencountries and nations worldwide, including India and Cambodia,for many different medical treatments.

What it does: The bark is a rich source of ellagic acid, another an-tioxidant that has been shown in some exciting studies to be ananticarcinogen. The fruit is a rich source of antioxidant vitaminC. Oral preparations using some form of P. emblica traditionallyhave been used to prevent and treat hepatitis, certain forms ofcancer, and to strengthen the immune system.

Where to get it: To date, P. emblica isn’t widely available, though itmay be prescribed orally by some Ayurvedic medical practition-ers. Stay tuned.


S E L E N I U M

What it does: In the last ten years, scientists have discovered thatthis mineral, which works in tandem with vitamin E as an an-tioxidant, may play a role in preventing cancer, heart disease, and


some strains of flu. It seems to keep our tissues (including ourskin) elastic and prevent them from hardening due to oxidation(free radical damage). For this reason, scientists are optimistic thatselenium is a key component in slowing down the aging process.Recent animal studies also have shown that either when takenorally or applied topically in the form of L-selenomethionine,selenium protects us against both daily incidental and excessivesun damage. Its other health benefits may include playing a rolein thyroid function, which regulates the metabolism. And ahealthy metabolism equals healthy skin.

Where you can find it: Selenium is readily available in nonprocessedfoods, including meats; shellfish; garlic; vegetables; grains, such asoats grown on selenium-rich soil; and Brazil nuts.

USRDA: 55 mcg per day for women; 70 mcg per day for men.

How to meet it: While the nutritional community hasn’t yet calcu-lated the precise selenium values in specific foods, it is consideredto be one of the easier nutrients to get enough of since it is sowidespread.

S O Y

What it is: A legume native to Asia that’s extensively cultivated fora variety of different food sources.

What it does: Some studies have associated soy with a lower risk fordeveloping heart disease and lower incidences of cancers of thebreast, colon, uterus, and prostate. Other studies have used soy tolower cholesterol levels, treat hot flashes, and increase bone den-sity during and after menopause. These reported benefits mighthave something to do with certain “magical” compounds called


isoflavones, also known as phytoestrogens. Phytoestrogens are, inessence, plant estrogens and have some of the same positive effectson the body as natural human or man-made estrogen withoutsome of the negative effects.

Soy’s effects on skin have been found to be extremely benefi-cial in promising and exciting research from Switzerland’s Dr.Genistein, who appears to have isolated one of the key isoflavonesfor skin health. Studies throughout Europe have shown thatgenistein helps to suppress our body’s enzymes that erode colla-gen. It also appears to react with our skin’s estrogen receptors likeactual estrogen without any of the negative side effects of hor-mone replacement therapy (HRT). Several new studies haveshown that our collagen-producing fibroblasts have estrogen re-ceptors in them, which would make estrogen an important partof collagen synthesis.

Where you can find it: Soybean, edamame, tofu, tempeh, soy milk,and prepared foods such as soy burgers, soy chips, and veggieburgers.

USRDA: None yet established, though The American Heart Associ-ation recently concluded that 25 to 50 grams of soy a day can helplower levels of LDL, or bad cholesterol, by as much as 8 percent.

IMPORTANT NOTE: Some important studies, including one pub-lished in the Journal of Cancer Research, concluded that eatingisoflavone-enhanced supplements containing genistein may coun-teract the tumor-fighting effects of Tamoxifen, a commonly pre-scribed medication for women battling estrogen-dependentbreast cancer. It has been theorized in an important study thatone possible explanation for these findings is the fact that our soysupplements and fortified foods may contain too many isoflavones.In Asia where cancer rates are lower, people often consume diets


rich in soy products that contain about 20 to 30 milligrams ofisoflavones. However, many isoflavone-enhanced drinks and sup-plements here may contain 30 to 150 milligrams per serving andoften two or more servings a day are recommended on the labels.Several organizations are continuing to research soy’s possible rolein preventing breast and other cancers and/or furthering it incases of estrogen-dependent breast cancer. If you have cancer, orare genetically predisposed to it, it’s best to check with your doc-tor before taking any oral supplements.

S U L F U R

What it is: Sulfur is an element that occurs naturally in the body asa component of the amino acids cysteine and methionine, whichmeans it plays an important role in the structure and thickness ofalmost all our body’s proteins (including collagen), antibodies,and enzymes.

What it does: In terms of skin, sulfur has been found to play a ma-jor role in maintaining the solid structure of keratin—a key pro-tein in our hair and nails—and the softer, less rigid, keratin thatmakes up skin. As a key part of chondroitin sulfate, sulfur also hasbeen found to both stimulate the secretion and increase the vis-cosity of the fluids that condition our joints and skin. In additionit helps fend off the body’s enzymes that break down joints. It alsohas a powerful anti-inflammatory action on connective tissue dis-ease as well as the ability to regulate immune response. For thesereasons, according to promising research, it is thought to play akey role in our skin’s health, fending off and perhaps even revers-ing the signs of premature aging, though more studies are neces-sary to confirm these findings.


Where you can find it: The major food sources for sulfurs are pro-teins that contain methionine and cysteine. These include: beans,eggs, beef, pork, and poultry. In addition, unless labeled sulfur-free, dried fruit can be a good source.

USRDA: None. For now, it is assumed that if you eat an adequateamount of protein, you will take in a sufficient amount of sulfur.

V I T A M I N A

What it does: In addition to being essential for good vision, as wellas healthy bones and teeth, vitamin A, which is fat soluble, is alsoa powerful antioxidant that may play a role in preventing cancer.It is also key to normal cell development and reproduction andhelps to maintain our body’s mucous membranes (the linings ofthe cavities and canals of the body that are exposed to air, suchas the inside of the mouth and nose). Vitamin A is also an impor-tant component of the development and preservation of our ep-ithelial tissues (the layers of the body that serve as selectivebarriers to the environment; they include our cornea, skin, respi-ratory lining, and the lining of the digestive tract). Scientists alsobelieve vitamin A may prevent premature wrinkling and bumpyor sandpaper-like skin. Vitamin A deficiencies can result in rough,dry, scaly, skin.

While more research needs to be done for conclusive evi-dence, some promising studies also have suggested that whenconsumed, vitamin A may provide protection against sunburnbecause of its ability to absorb light. The studies found that mod-erate amounts of vitamin A (30 mg/day) taken before and duringsun exposure gave additional protection against sunburn, possiblybecause the vitamin A in the body worked synergistically with the


physical protection of the sunscreen. It also has been suggestedthat vitamin A supplements increase skin’s reflective abilities,thereby improving its own natural sun protection.

Where you can find it: In nature, vitamin A exists only in its precur-sor form carotene, a yellow orange pigment that our bodies con-vert into vitamin A, and beta-carotene, a form of a carotene thatour bodies also transform into vitamin A. Carotenes and beta-carotenes are the most abundant in leafy vegetables and dark col-ored fruits, such as carrots, cantaloupe, sweet potato, butternutsquash, spinach, dandelion greens, and turnip greens. They arealso present in cow’s liver, fish, and dairy products.

USRDA: 700 mcg per day for women; 900 mcg per day for men.

How to meet it: Concentrated sources include: ½ cup cookedcarrots, 1915 mcg; ½ cup mashed sweet potato, 1936 mcg; and ½cup spinach, 737 mcg. Other less concentrated sources include:one cup fortified milk, 140 mcg; and 6 fresh apricots, 560 mcg.

V I T A M I N B C O M P L E X

What it does: Vitamin B is actually a complex of water-soluble nutri-ents that work together synergistically. So if you are taking a B vita-min, make sure it contains all nine forms of it to ensure maximumbenefits. While each component may have slightly different func-tions, as a whole, B complex is a coenzyme that is essential in help-ing the body to metabolize macronutrients, such as fatty and aminoacids, and carbohydrates. It also helps maintain the health of thenerves, skin, eyes, hair, liver, and mouth, as well as healthy muscletone in the gastrointestinal tract and proper brain function.


In terms of skin health, inadequate amounts of vitamin B canlead to rashes (B2, riboflavin, B6, and biotin); cracks at the cornersof the mouth (B2, riboflavin); and dry skin, rash, loss of hair, brit-tle hair and nails (biotin). One component of folic acid, para-aminobenzoic acid (PABA), helps to create pantothenic acid,which is believed to be an antioxidant that helps protect againstsunburn and skin cancer. A deficiency of PABA may lead topatchy areas of white skin.

Where you can find it: While each component of vitamin B complexmay be found in different foods, whole grains, fortified cereals,green vegetables, red meat, organ meats, dairy, fish, and nuts gen-erally are your richest sources for most of them.

USRDA and how to meet it:

� B1 (thiamin): 1.1 mg per day for women, 1.2 mg

per day for men. Some foods that contain it

include: a 3.1 oz. broiled pork chop, .33 mg;

1 tablespoon brewer’s yeast, 1.25 mg; ¼ cup

sunflower seeds, .80 mg; 3 oz. ham .78 mg.

� B2 (riboflavin): 1.1 mg per day for women, 1.3mg

per day for men. Some foods that contain it

include: 1 cup yogurt, .58 mg; 1 cup cooked

mushrooms, .48 mg; 1 cup part-skim ricotta, .46

mg; 1 cup cooked spinach, .42 mg.

� B3 (niacin): 14 mg per day for women, 16 mg per

day for men. Some foods that contain it include:

3 oz. tuna packed in water, 10.6 mg; ½ roast

chicken breast, 6.2 mg; 1 cup cooked mush-

rooms, 7 mg, 3 oz. beef liver, 12.2 mg.

� Folate (folic acid): 400 mcg per day for men and

women, though needs increase to 600 mcg per


day for pregnant women to prevent neural tube

defects. Some foods that contain it include:

1 cup black-eyed peas, 350 mcg; 1 cup spinach,

260 mcg; 1 cup pinto beans, 295 mcg, 1 cup as-

paragus, 175 mcg.

� B6 (pyridoxine): 1.3–1.7 mg per day for men and

women. Some foods that contain it: a banana,

.6 mcg; 3 oz. sirloin steak, .45 mcg; 3 oz. turkey,

.48 mcg; 1 cup spinach, .48 mcg.

� B12 (cyanocobalmin): 6 mcg per day for men and

women. Some foods that contain it include:

1 cup milk, 2 mcg; ½ oz. cheese, 2 mcg; 1 egg,

2 mcg.

� Pantothenic acid: 10 mg per day for men and

women. While information concerning exact

amounts of pantothenic acid in foods is in-

complete, good sources include: chicken, beef,

grains, oats, cereal, potatoes, tomatoes, egg yolk,

and broccoli.

� Biotin: 30 mcg per day for men and women. No

one officially has determined the exact amounts

of biotin in food but it is definitely present in

liver, meats, brewer’s yeast, egg yolks, soybeans,

saltwater fish, and whole grains.

V I T A M I N C ( A S C O R B I C A C I D )

What it does: This proven antioxidant protects our skin and organsfrom the harmful degenerative effects of free radicals that cancause the cell damage that may contribute to the development ofcardiovascular disease, cancer, and other illnesses, as well as pre-


mature aging. Vitamin C has also been shown to be necessary fortissue growth and repair, as well as collagen formation. Since itworks synergistically with vitamin E, it is recommended that youmake sure you get enough of both of these vitamins to receivetheir maximum benefits.

Where you can find it: Citrus fruits, such as grapefruits, lemons, or-anges, and tangerines; other fruits including berries, mangoes, ap-ples, and pineapples; tomatoes; yellow, red, and orange peppers;green vegetables, such as asparagus, avocado, broccoli, kale, andspinach.


How you can meet it: It’s easy to incorporate enough C into yourdiet because it’s found in concentrated amounts in a lot of differ-ent foods. For example, ½ cup of chopped fresh red pepper has 95mg; 1 cup strawberries, 84 mg; 1 cup orange juice, 93 mg; 1grapefruit, 94 mg; ½ cup broccoli, 58 mg, and ½ cup brusselssprouts, 48 mg.

V I T A M I N D ( C A L C I F E R O L )

What it does: Vitamin D’s main claim to fame is that it is essentialfor the growth of our bones and teeth and for our absorption andutilization of calcium and phosphorous. This function makes itan important nutrient in the treatment and prevention of osteo-porosis, a dangerous decrease in bone mass, and the less severeosteopenia. It is also involved in regulating the heartbeat, protect-ing against muscle weakness, and is essential for normal bloodclotting.

When it comes to skin, some clinical studies have shown thatvitamin D, which is fat soluble, may help make the symptoms of


psoriasis less severe. In addition, vitamin D is involved in main-taining normal thyroid function, which is essential to healthyskin.

Where you can find it: The form of vitamin D we get from food andsupplements doesn’t become active without the help of our bod-ies. Then our skin gets into the act. When we go out into the sun,the UV rays transform a cholesterol compound in our skin intothe precursor of vitamin D, which is then converted into its activeform by our liver and kidneys. Experts have found that exposingour face or arms to the sun for just 15 minutes 3 times a week isa sufficient way to get enough vitamin D. It can also be found infish liver oils; vegetable oils; fatty saltwater fish, like halibut,salmon, tuna, sardines, and shrimp; dairy products; egg yolks;and dandelion greens.

USRDA: Anywhere from 5 to 15 mcg per day depending on age.Growing children and adolescents require more than adults.

How to meet it: 3 oz. of shrimp, 3 mcg; 2 eggs, 1.3 mcg; 1 cup ofmilk, 2.5 mcg; 3 oz. of mackerel or salmon, 8 mcg; 3 oz. blue fintuna, 4 mcg.

V I T A M I N E ( T O C O P H E R O L )

What it does: Vitamin E is a fat-soluble vitamin that actually existsin eight forms, called tocopherols. Each form has its own functionin our bodies. Alpha-tocopherol is the most active form for ussince it is the most easily absorbed by our bodies. It is anotherpowerful antioxidant that defends us against and disables meta-bolic free radicals. It also improves our circulation; protects themembranes of our red blood cells; safeguards our white bloodcells, which help our bodies fend off disease; plays an important


role in our nerve development; and is a necessary component oftissue repair.

Where you can find it: Vegetable oils, including canola, flaxseed, corn,safflower, soybean, and wheat germ; nuts, seeds, and legumes, suchas sunflower seeds, walnuts, and soybeans; whole grains and forti-fied cereals, including brown rice, cornmeal, and oatmeal. There isalso a small amount of vitamin E in meat, poultry, fish, and eggs.

USRDA: 15 mg per day of the alpha-tocopherol form for men andwomen. Unlike other vitamins, the form of alpha-tocopherolmade in the laboratory and found in supplements is not identicalto the natural form, and isn’t quite as active. For this reason, someexperts in the medical community are now recommending thatwe take supplements with mixed tocopherols, such as beta,gamma, and delta along with alpha.

How you can meet it: ½ cup mashed sweet potato has 4.5 mg; 2 ta-blespoons sunflower seeds, 9 mg; 1 tablespoon canola oil, 2.9 mg.

V I T A M I N K

What it does: Vitamin K is essential to blood clotting and the mak-ing of a protein in our blood that regulates calcium in our blood-stream. It is also necessary for bone function and repair, and thesynthesis of osteocalcin (a protein in bone tissue on which cal-cium crystallizes) and so may help prevent osteoporosis. VitaminK heals and prevents broken blood vessels. In fact, symptoms ofvitamin K deficiency include easy bruising and ruptured capillar-ies, a key cause of dark under-eye circles.

Where you can find it: Green veggies, such as collard greens, spinach,salad greens, and broccoli; brussels sprouts; cabbage; plant oils;


garbanzo beans; eggs; milk; beef liver. Small amounts are alsofound in: tomatoes, lima beans, apricots, potatoes, grapes, cauli-flower, peaches, plums and squash.

USRDA: 90 mcg per day for men and women.

How to meet it: Precise levels of the vitamin K content of foods havenot yet been determined. But here are some estimates most widelyconsidered to be the most accurate: 3 oz. dark green leafy veggies,50 to 800 mcg; 3.5 oz. of Swiss chard or kale, 800–830 mcg;3.5 oz. brussels sprouts or spinach, 400–440 mcg.

IMPORTANT NOTE: Since an excess amount of vitamin K in supplementform can easily reach harmful levels, it is only available as a singledose by prescription. Toxic side effects from excess supplementa-tion may include: breakage of red blood cells and the release oftheir pigment, which turns skin yellow, and more seriously, braindamage. If you take anticoagulants, your doctor might advise youto avoid or limit the foods that contain vitamin K, due to its clot-ting effects.

W H I T E T E A

What it is: A specific form of tea, mostly grown in China, in whichthe leaves and buds are simply steamed and dried, rather than un-dergoing the withering and various degrees of oxidation thatblack, oolong, and green teas are processed with.

What it does: Studies have shown that white tea may be extremelyeffective in fending off DNA mutations and certain forms of can-cers due to its high polyphenol content, which has been found tobe an effective weapon against free radical damage. Many re-searchers believe white tea is so high in antioxidants because it


undergoes minimal processing and so is able to maintain its pro-tective powers. White tea has also been found to protect the skin’slipid content, both when applied topically and taken internally.

Where you can find it: In silver-tip white tea leaves and tea bags.

USRDA: None so far. But again, people in Asian cultures tend todrink several cups of white tea on a daily basis.


The Next Wave in Antioxidants

Four Extremely Promising New Comers

Much remains to be learned about the following antioxidants toconfirm the exact nature of their actions and their effects on ourbodies: anthocyanins, bioflavanoids, lycopene, and P. emblica.The content in food of many of these antioxidants are still un-known, which makes accurate estimates for our consumption ofthem and the correlation with their benefits difficult. And thoughwe do have more complete data on lycopene, the effects of pro-cessing and cooking bioflavanoids, anthocyanins, and P. em-blica, are not completely realized. We also aren’t completely surehow these antioxidants are absorbed into the bloodstream. Butin general, the scientific and medical communities are highlyoptimistic that more research will help back up the health claimsof existing studies. Applying them topically is a safe and effectiveway for the skin to benefit from them.

Z I N C

What it does: This mineral is essential for our normal growth anddevelopment and the functioning of our immune system and re-productive organs. It also plays a significant part in our night vi-sion and sense of taste. In addition, zinc is a key nutrient in helpingto maintain the health of our skin, hair, and bones. Some studieshave also found that zinc links together the amino acids that arenecessary for collagen formation and essential to healing wounds.It has also been shown to help prevent damage to our skin’s colla-gen and elastin fibers.

Where you can find it: Meat, shellfish, and poultry are the most con-centrated sources of zinc. Plant sources include some legumes,soybeans, and whole grains, but our bodies do not as easily absorbthem.


How to meet it: 6 medium battered and fried oysters, 16 mg; 3-oz.pork shoulder, 4.8 mg; 3 oz. beef tenderloin, 4.8 mg; 3 oz. porktenderloin, 2.5 mg; ¾ cup ready-to-eat breakfast cereal, fortifiedwith 100 percent of the USRDA for zinc per serving, 15.0 mg; 1cup plain low-fat yogurt, 2.2 mg; ½ cup baked beans, 1.7 mg; 1oz. dry roasted, unsalted cashews, 1.6 mg.


Active Ingredients ChecklistyT H E E S S E N T I A L S F O R A N E F F E C T I V E

D A I L Y A N T I A G I N G R E G I M E N

W e’ve covered a lot of ground in the previous pagesand while getting and maintaining young and beau-tiful skin may seem complicated, it’s actually quite

simple. The cornerstone is a solid daily regimen that in additionto appropriate cleansing and moisturizing includes products withproven active ingredients that:

� Protect against the sun, free radicals, and our

collagen-degrading enzymes.

� Speed up cell turnover to keep skin clear, smooth,

and evenly toned.

� Build collagen and elastin to stave off lines,

wrinkles, and sagging and to minimize their ap-

pearance.

192 A C T I V E I N G R E D I E N T S C H E C K L I S T

The ingredients that achieve those results are available invarying forms (e.g., creams, lotions, gels, serums, and pads), atdifferent locations (e.g., your local drugstore, department store,specialty boutique, online, at your dermatologist’s office), and atvarying price points. The main thing is to pick formulationsgeared to your skin type that are pleasant to use with a price tagthat you are comfortable with. Remember, higher prices don’tnecessarily mean more efficacious products, though they gener-ally do mean a product with more medical-grade ingredients.

Look for skin-care therapies that contain muliple active ingre-dients. These products are usually more effective than productsthat only contain one active ingredient because they take a multi-faceted approach to treating the skin.

You might find that it’s necessary to fine-tune your regimendepending on the season, and if you are traveling or taking anymedications, these factors can affect your skin balance to promoteirritation and inflammation, which can accelerate the aging processby producing free radicals. Products that cause up to three min-utes of tingling, not burning, are fine but more than that may bea sign of irritation. (Reread chapter 4 to review how.) But if aproduct burns, causes itching, flaking, or redness, stop using itimmediately. Similarly, if you are not seeing some kind of positiveresults after four to six weeks, it’s time to move on. With all of thisin mind, here is your cheat sheet of essential antiaging actions andtheir corresponding ingredients that should be used daily:

P R O T E C T I O N

Sun

Look for products that offer broad spectrum UVA/UVB protec-tion geared for your skin type with a minimum of SPF 15.

A C T I V E I N G R E D I E N T S C H E C K L I S T 193

Free Radical

Proven antioxidants to fight free radicals include vitamins Cand E. Up and coming ingredients with promising research be-hind them are:

� Lycopene, found in tomatoes, watermelon, red

grapes, and pomegranate

� Green tea extract

� White tea extract

� Grapeseed extract

� Beta-Carotene, a provitamin A, found in carrots,

and dark leafy greens

� Bioflavanoids, found in blueberries and raspberries

� Anthocyanins, found in red grapes

� P. emblica extracts from the fruit, bark, and/or

leaves of the Phyllanthus emblica tree.

Collagen Erosion:

� Retinoids: Nonprescription strength retinol; pre-

scription strength tretinoins used in Retin-A and

Renova

� Genistein: a component of soy extract.

S P E E D U P C E L L T U R N O V E R

T H R O U G H E X F O L I A T I O N

� Alpha Hydroxy Acids: A class of acids that occur

naturally in foods. These include:

Glycolic: from sugar

Lactic: from milk

Citric: from citrus fruits

Malic: from apples

194 A C T I V E I N G R E D I E N T S C H E C K L I S T

� Beta Hydroxy Acids: Currently, Salicylic Acid is

the only beta hydroxy acid used in skin care.

While it’s synthetic, it is close to the molecular

structure to an acid that occurs naturally in skin,

so it is generally nonirritating.

B U I L D C O L L A G E N A N D E L A S T I N S T O R E S W I T H

� Vitamin C

� Vitamin A-derived retinoids: Nonprescription

strength retinol; prescription strength, tretinoins

� Genistein: This soy derivative works like estrogen

without negative side effects to prompt the skin’s

collagen-producing fibroblasts to get moving.

O P T I O N A L P R O B L E M S O L V E R S

Lighten Dark Spots with:

Bleaching Agents:� Kojic Acid: Available in both prescription and

nonprescription strength

� Hydroquinone: Available in both prescription

and nonprescription strength

� Vitamin C in the form of ascorbic acid

� Vitamin K: To heal broken capillaries to help

prevent them from leaking iron and blood cells

in the under-eye area, which gives it a dark

appearance.

A C T I V E I N G R E D I E N T S C H E C K L I S T 195

Deflate Puffy Under-Eyes with:

Natural Diuretics:� Cucumber extract

� Caffeine

Anti-irritants� Green tea extract

� White tea extract

R E S O U R C E L I S T

This compiled list of resources can answer any questions you mayhave after reading this book, or about other products, procedures,or health information you’ve heard about.

For more information on Dr. Gross, his practice, and the M.D.Skincare line:

M.D. Skincare444 Madison Ave8th FloorNew York, NY 10022Phone: 1-888-830-SKIN (1-888-830-7546)wwd.mdskincare.comwww.drdennisgross.com

198 R E S O U R C E L I S T

To check the board certification status of a dermatologist:

The American Board of DermatologyAmerican Board of DermatologyHenry Ford Health System1 Ford PlaceDetroit, Michigan 48202-3450Phone: 313-874-1088Fax: 313-872-3221www.abderm.orgE-mail: [email protected]

For more information on skin concerns and procedures:

The American Academy of DermatologyP.O. Box 4014Schaumburg, IL 60168-4014Phone: 847-330-0230Fax: 847-330-0050www.aad.org

The American Academy of Dermatology cannot answer medicalquestions, give referrals to specific dermatologists, or endorseproducts.

To contact the AAD for more information about locating adermatologist, call 888-462-DERM (888-462-3376):

American Society for Dermatologic Surgery5550 Meadowbrook Dr.Suite 120Rolling Meadows, IL 60008


Phone: 847-956-0900Fax: 847-956-0999www.asds-net.orgE-mail: [email protected]

To check the board certification status of a plastic surgeon:

The American Board of Plastic SurgerySeven Penn Center, Suite 4001635 Market StreetPhiladelphia, PA 19103-2204Phone: 215-587-9322Fax: 215-587-9622abplsurg.orgE-mail: [email protected]

For more information on plastic surgery procedures and/or tofind a board certified plastic surgeon in your area:

American Society of Plastic SurgeonsPlastic Surgery Educational Foundation444 E. Algonquin Rd.Arlington Heights, IL 60005Plastic Surgeon Referral Service: 1-888-4-PLASTIC (1-888-475-2784)www.plasticsurgery.org


The American Society for Aesthetic Plastic SurgeryRaleigh, North Carolina 27607-7506Phone: 919-881-2570Fax: 919-881-2575Find a surgeon and cost information: 1-888-ASAPS-11 (1-888-272-7711)www.surgery.org E-mail: [email protected]

To check the board certification status of an anesthesiologist:

American Board of AnesthesiologyYou may check board status free of charge by:

� Using the Online Diplomate Directory� Calling the ABA at 919-881-2570� Calling the American Board of Medical

Specialties toll free at 866-ASK-ABMS (866-275-2267)

www.abanes.orgThe board does not accept correspondence via e-mail.

For more information on health care and concerns:

The National Library of Medical ConcernsBethesda, MD 20894Phone: 888-FIND-NLM (888-346-3656)Fax: 888-346-3656http://www.nlm.nih.gov


For more information on the safety and efficacy of skin-care prod-ucts and procedures:

Food and Drug Administration5600 Fishers LaneRockville, MD 208571-888-INFO-FDA (1-888-463-6332)http://www.fda.gov

For more information on alternative and holistic medical proce-dures, products, and nutrition:

The National Center for Complementaryand Alternative MedicineNCCAM ClearinghouseP.O. Box 7923Gaithersburg, MD 20898Phone: 888-644-6226International: 301-519-3153TTY:1-866-464-3615 (for hearing impaired)Fax: 1-866-464-3616www.nccam.nih.govE-mail: [email protected]

For more information on food and nutrition:

The Food and Nutrition Information Center at the National Agricultural LibraryAgricultural Research Service, USDANational Agricultural Library, Room 105


10301 Baltimore AvenueBeltsville, MD 20705-2351Phone: 301-504-5719Fax: 301-504-6409TTY: 301-504-6856www.nal.usda.gov/fnicE-mail: [email protected]

NUTRITION.GOVwww.nutrition.gov

I N D E X

Accutane, 32, 45Acids

alpha hydroxy, 29, 40, 193amino, 168beta hydroxy, 29–30, 194essential fatty, 171–72hyaluronic, 58, 60, 85, 86–87peels, 58, 62, 74, 77Trichloroacetic, 139

Acne, adulthormonal fluctuations relating to,

45–47treatment of, 45–47, 78–79

Active ingredient checklist, 191–95Age-erasing options. See Level 3: age-

erasing optionsAge range

in Level 1: care/prevention, 25in Level 2: repair/protection, 57in Level 3: age-erasing options,

91in Level 4: major changes, 125

Aging patternsaging process impacted by, 8–9in Skin Life Cycle Quiz, 4

Aging patterns, key predictors ofexpressionless face as, 3, 23genetics as, 3, 22–23impact of sun as, 3, 24tired v. rested face as, 3, 23–24

Aging process, rate ofaging patterns’ impact on, 8–9genetics’ impact on, 3, 5–6, 8–9lifestyle’s impact on, 5, 7–9personal feelings’ impact on, 8–9present condition’s impact on,

8–9stresses’ impact on, 7–8sun exposure’s impact on, 30–31time’s impact on, 5, 6–7

Aging skingenetics relating to, 5–6, 8–9process of, 1, 26signs of, 21–22

Alcoholskin relating to, 166–67toner with, 28

Alpha hydroxy acid, 29, 40, 193American Academy of Dermatology,

198American Board of Anesthesiology, 129,

199–200American Board of Dermatology, 197American Board of Plastic Surgery, 128,

129, 198–99American Heart Association, 156American Society for Aesthetic Plastic

Surgery, 128, 199American Society for Dermatologic

Surgery, 198American Society of Plastic Surgeons, 92,

128, 199Amino acids, 168Anthocyanins, 168Antiaging

research/studies of, 2techniques of, 1–2

Anti-irritants, 194, 195Antioxidants

benefits of, 61decrease in, 26in food, 164topical application of, 188types of, 35–37, 61under-eye area treated with, 39vitamin C as, 36–37, 101

Artecoll, 107, 110, 142, 148Autologous fat transfer, 87–88

Beta hydroxy acid, 29–30, 194Bioflavinoids, 168–69Biotin, 132Bleaching products, 32, 74–76, 194Blepharoplasty, 110, 129, 150–52Botox, 58

age-erasing with, 92, 101–7, 115, 120

benefits of, 79–81in level 4, 126–29, 133–37, 145–46,

150

lines/wrinkles with, 79–84, 103–7Myobloc v., 83–84risks of, 81–82under-eye area treated with, 74

Brow/forehead, 104–5, 146–48

Caffeine, 167Capillaries, broken

age-erasing options for, 119care/prevention of, 28, 54repair/protection of, 54, 76–77

Cell turnoveralpha hydroxy acids relating to,

193beta hydroxy acids relating to, 194exfoliation relating to, 61–62slowing of, 26, 29

Cervicoplasty, 145Checklist, active ingredient, 191–95Chemical peel. See PeelsChest. See Neck/chest, treatment ofChicken pox scars, 78–79Cleanser, 28Coblation, 114Coenzyme Q-10, 169–70Collagen

care/prevention with, 37–39, 56, 131,132

decrease in, 26genistein with, 193, 194increase in, 29, 66–69laboratory-grown, 89repair/protection with, 85–86, 193,

194retinoids relating to, 67, 193, 194vitamin C boosting, 37–39, 123, 126,

128, 193, 194Zyderm as type of, 86, 103, 105Zyplast as type of, 86, 103, 104

Copper, 170Cosmoderm, 103–4, 106CO2 laser, 134, 137, 138Creases/wrinkles/depressions, 84–89

autologous fat transfer for, 87–88collagen for, 85–86deep, 140–45

204 I N D E X

hyaluronic acid fillers for, 58, 60, 85,86–87

laboratory-grown human collagen for,89

Crow’s-feet, 105–6

Daily regimen, products forcell turnover increased by, 193–94collagen/elastin built with, 194dark spots lightened by, 194protection with, 192–93under-eye puffiness deflated by, 195

Dark circles, 49–50, 110–11Deep chemical peels, 135, 138–39Deep creases/wrinkles/depressions,

140–45Deep laser resurfacing, 92, 103, 115–20,

135–40Depressions. See Creases/wrinkles/

depressionsDermabrasion, 135, 139Dermatitis/seborrheic dermatitis, 45, 49,

89Diet, 164–89Discolorations. See Sunspots/discol-

orationsDiuretics, natural, 194, 195

Eczema, 28Elastin

decrease in, 26genistein with, 193, 194increase in, 29, 37–39, 56, 131, 132repair/protection with, 66–69, 85–86,

193, 194vitamin C boosting, 37–39, 123, 126,

128, 193, 194Electrostimulation, 111–12Endoscopic surgery, 129Erbium laser, 111, 116Essential fatty acids, 171–72Exercise routine, 5, 156Exfoliation, 29–30, 37, 61–66

cell turnover increased by, 61–62light acid peels used in, 62“Phlux” relating to, 62

Eyelids, 149–52Eyes. See Under-eye area

Faceas expressionless, 3, 23tired v. rested, 3, 23–24

Face-lift, 58, 128, 140–45Facials, 43Feather Lift (minilift), 129, 142–43Feingold, Karen, 163Fillers

hyaluronic acid-based as, 58, 60, 85,86–87

in level 4, 127–29, 133–35, 148–49lines/wrinkles treated with, 79–84,

103–7permanent, 58, 107–10, 142, 144, 148

Foodantioxidants in, 164supplements v., 165

Food and Drug Administration, 200Food and Nutrition Information Center

at the National Agricultural Library,201

Forehead/brow, 104–5, 146–48Free radicals

age-erasing options relating to, 97care/prevention relating to, 35–37, 193

Geneticsaging patterns relating to, 3, 22–23aging process predicted by, 3, 5–6,

8–9Genistein, 61, 63, 97, 110, 111, 132,

193, 194Gore-Tex cheek lift, 142, 144Green tea, 172–73

Hands, care of, 98–99, 118–20Healthy habits

benefits of, 153–62exercise as, 156gentle cleansing as, 161knee care as, 156–57makeup removal relating to, 160–61nonsmoking as, 155

I N D E X 205

Healthy habits (cont.)satin pillowcase relating to, 155–56skin-care products as, 160sleep as, 154sunglasses relating to, 161sunscreen relating to, 162temperature relating to, 157–58travel schedule relating to, 159water relating to, 159–60weight maintenance as, 158–59

Heart healthy, 164Hemangiomas, 119Hormonal fluctuations, 45–47Hormone Replacement Therapy (HRT),

96–97Hormones, 96–97Human Growth Factor (HGF), 99Humidity, skin and, 100Hyaluronic acid-based fillers, 58, 60, 85,

86–87Hydrocortisone cream, 49Hyperpigmentation, 50

Implants. See Surgical implantsInflammation/irritation, treatment of,

71–72Iraderm Diode Laser, 76, 77Iron, 173–74Irritation/inflammation, treatment of,

71–72

Jowls, 145–46

Knee care, 156–57

Laboratory-grown human collagen, 89Lasers

age-erasing with, 101–7CO2, 134, 137, 138deep laser resurfacing as, 92, 103,

115–20, 135–40Erbium, 111, 116Iraderm Diode, 76, 77nonablative treatments by, 58, 68–69,

106–7, 110, 115, 137, 148, 149pulsed-dye, 77

ruby, 75–76Smooth Beam, 68, 69, 87, 101, 111,

120YAG, 75–76, 119, 135

Level 1: care/preventionage range in, 25aging process in, 26application order in, 41–43moisturizer use in, 27–28product consistency in, 41results monitored in, 43–44skin’s condition in, 25–26sun protection in, 42, 56sunscreen in, 18, 27, 30–35, 39, 126,

137Level 1: care/prevention, basics of

collagen/elastin boosted as, 37–39, 56,131, 132

daily exfoliation as, 29–30facials/masks as, 43free radicals fought as, 35–37, 193skin type assessed as, 26–40, 27–28sun damage prevented as, 26, 30–35under-eye area pampered as, 39–40

Level 1: care/prevention, treatment inacne as, 45–47broken capillaries as, 28, 54dark circles as, 49–50lines/wrinkles/sagging as, 54–56puffy under-eyes as, 50–52rosacea as, 28, 47–49seborrheic dermatitis as, 49sunspots/discolorations as, 52–53

Level 2: repair/protection, 18–19age range in, 57irritation/inflammation in, 71–72microdermabrasion in, 71sunscreen in, 67, 69, 70, 76symptoms of, 57–58temporary procedures in, 58–59

Level 2: repair/protection, basics ofcollagen/elastin increased as, 66–69,

85–86, 193, 194exfoliation as, 61–66genistein as, 61, 63neck/chest treatment as, 69–70

206 I N D E X

retinol as, 61water content as, 59–60

Level 2: repair/protection, treatments inacne/chicken pox scars in, 78–79broken capillaries in, 54, 76–77creases/wrinkles/depressions in, 84–89enlarged pores in, 78lines in, 79–84rosacea in, 77–78sunspots/discolorations in, 74–76under-eye area in, 73–74

Level 3: age-erasing optionsadjustments to, 19–20, 120–24age range in, 91antioxidants as, 101Botox as, 92, 101–7, 115, 120deep laser resurfacing as, 92, 103,

115–20laser as, 101–7peels as, 101–7permanent procedures in, 93–94sunscreen as, 101, 123surgical procedures as, 91–92, 101symptoms/concerns of, 91–93

Level 3: age-erasing options, basics ofcare of self as, 94–95free radicals fought as, 97hand care as, 98–99hormones relating to, 96–97humidity relating to, 100moisturizer’s use as, 96skin assessment as, 95–96sulfur relating to, 98, 111

Level 3: age-erasing options, treat-ments in

broken capillaries in, 119lines/wrinkles in, 103–10neck/chest/hands in, 118–20sagging in, 111–14, 119–20under-eye area in, 110–11

Level 4: major changes, 20–21age range in, 125concerns of, 125–29strategies for, 125–29

Level 4: major changes, areas ofdeep creases as, 140–45

eyelids as, 149–52forehead as, 146–48lax skin as, 135–40mouth/lips as, 148–49neck/jowls as, 145–46sagging skin as, 140–45

Level 4: major changes, treatments inblepharoplasty as, 150–52Botox, 126–29, 133–37, 145–46, 150care of self as, 130–31, 133cervicoplasty as, 145deep laser resurfacing, 135–40face-lifts as, 128, 140–45forehead/brow lift, 146–48Gore-Tex cheek lift as, 142, 144lipectomy as, 145liposuction as, 145minilift (Feather Lift) as, 129, 142–43natural defenses bolstered as, 131–32platysmaplasty, 145skin assessment as, 131subconjunctival blepharoplasty as, 129surgical implants as, 58, 144–45vitamin B as, 132–33vitamin K as, 132

Light acid peels. See PeelsLines

care/prevention of, 54–56repair/protection of, 79–84

Lines/wrinkles, areas ofbrow/forehead as, 104–5crow’s-feet as, 105–6lips as, 106–7nasolabial folds as, 104

Lines/wrinkles, treatment forBotox/fillers as, 79–84, 103–7nonablative laser for, 106, 107permanent fillers as, 58, 107–10, 142,

144, 148Lipectomy, 145Liposuction, 145Lips, 106–7, 148–49Lycopene, 36, 174–75

Magnesium, 175–76Makeup removal, 160–61

I N D E X 207

Masks, 43M.D. Skincare, 202

Alpha Beta Peel, 63Antioxidant Face-Firming Complex,

36Cleanser, 28Lift & Lighten Cream, 50

Melanin, melanocytes, 34, 35Melasma, 52–53, 74Menopause, 60Microdermabrasion, 71Minilift (Feather Lift), 129, 142–43Moisturizer

alternatives to, 40–41effectiveness of, 40–41in level 1, 27–28in level 3, 96oil-free, 28sunscreen with, 4, 42for under-eye area, 39–40water content impacted by, 59–60

Mouth/lips, 148–49Myobloc, 83–84

Nasolabial folds, 104National Center for Complementary and

Alternative Medicine, 201National Library of Medical Concerns,

200Natural diuretics, 194, 195Neck/chest, treatment of, 69–70,

118–20, 145–46Nonablative laser treatments, 58, 68–69,

106–7, 110, 115, 137, 148, 149Nutrition.gov, 201

Oil glands, 27

Peelsage-erasing with, 101–7chemical, 29, 32deep chemical, 135, 138–39depths/strengths of, 65–66in level 4, 126, 127, 145–49light acid, 58, 62, 74, 77phenol as, 138–39

process of, 62–63results of, 63–64trichloroacetic acid (TCA), 139vitamin C with, 43

P. emblica, 176Peptides, 38–39Perlane, 103, 104, 106Permanent fillers, 58

Artecoll as, 107, 110, 142, 148Radiance as, 107, 109, 110, 148silicone as, 107, 108–9, 142, 144,

148Personal profile

creation of, 11–24The Skin Life Cycle Quiz used in,

12–18Personal profile, levels of

level 1: essential care/prevention, 18level 2: active repair/protection,

18–19level 3: age-erasing options, 19–20level 4: major changes . . . or not,

20–21Phenol, 138–39Plastic Surgery Educational Foundation,

199Platysmaplasty, 145Pores, enlarged, 27

repair/protection of, 78Profile. See Personal profilePuffy under-eyes. See Under-eye area

Radiance, 107, 109, 110, 148Resources, 197–202Restylane, 103, 105, 106, 121, 126Resurfacing, deep laser

CO2 laser as, 134, 137, 138deep chemical peels as, 135, 138–39dermabrasion as, 135, 139for level 3, 92, 103, 115–20for level 4, 135–40

Resurfacing, regional, 117–18Retin-A/Renova/Tazarotene, 32, 38, 67,

74, 95, 110, 132, 162Retinoids, 38, 50, 67, 132, 193, 194Retinol, 38, 39, 61, 66–67, 95, 110, 148

208 I N D E X

Rosacea, 28causes of, 47–49repair/protection of, 77–78symptoms of, 48–49

Sagging. See SkinSeborrheic dermatitis, 49Sebum, 27Selenium, 176–77Silicone, 107, 108–9, 142, 144, 148Skin

aging process of, 1assessment of, 131chemistry/biological makeup of, 1“controlled injury” to, 115healing abilities of, 26humidity relating to, 100natural defenses of, 26, 131–32products for, 160sagging, 54–56, 111–14, 119–20,

140–45Skin, age-erasing options of. See Level 3:

age-erasing optionsSkin care. See Level 1: care/prevention;

M.D. SkincareSkin Life Cycle Quiz

aging patterns identified by, 4development phase determined by, 4personal profile created with, 11–24

Skin, nutrition foramino acids as, 168anthocyanins as, 168bioflavanoids as, 168–69coenzyme Q-10 as, 169–70copper as, 170essential fatty acids as, 171–72green tea as, 172–73iron as, 173–74lycopene as, 174–75magnesium as, 175–76P. emblica as, 176selenium as, 176–77soy as, 177–79sulfur as, 98, 111, 179–80vitamin A as, 180–81vitamin B-complex as, 181–83

vitamin C as, 183–84vitamin D as, 184–85vitamin E as, 185–86vitamin K as, 186–87white tea as, 187–88zinc as, 189

Skin, repair/protection of. See Level 2:repair/protection

Skin, rules foralcohol relating to, 166–67antioxidants for, 164caffeine relating to, 167diet relating to, 164–65food v. supplements relating to, 165healthy heart as, 164water as, 165–66

Sleep, 154on satin pillowcase, 155–56

Smoking, 155Smooth Beam lasers, 68, 69, 87, 101,

111, 120Soy, 177–79SPF. See SunscreenStress, 7–8Sulfur, and skin, 98, 111, 179–80Sun

aging patterns impacted by, 3, 24damage by, 26, 30–35exposure to, 30–31protection from, 42, 56, 192

Sunglasses, 161Sunscreen

age-erasing options with, 101, 123benefits of, 4care/prevention with, 18, 27, 30–35,

39, 126, 137as healthy habit, 162moisturizer with, 4, 42repair/protection with, 67, 69, 70, 76for under-eye area, 4, 39

Sunspots/discolorationsmelasma relating to, 52–53, 74repair/protection of, 74–76treatments for, 53vitamin C helping with, 76

Surgical implants, 58, 144–45

I N D E X 209

Surgical procedures, 1, 91–92, 101blepharoplasty as, 110, 129,

150–52cervicoplasty as, 145endoscopic surgery as, 129implants as, 58, 144–45lipectomy as, 145liposuction as, 145platysmaplasty as, 145subconjunctival blepharoplasty as,

129

Teagreen, 172–73white, 187–88

Temperature, exposure to, 157–58ThermaCool/Thermage, 112–13Toner

alcohol-based, 28witch hazel-based, 28, 29

Travel, 159Trichloroacetic acid (TCA), 139

Under-eye areaage-erasing options for, 110–11anti-irritants for, 194, 195antioxidants relating to, 39Botox for, 74dark circles of, 49–50, 110–11moisturizer for, 39–40natural diuretics for, 194, 195puffiness of, 50–52, 195repair/protection of, 73–74sunscreen for, 4, 39vitamin C for, 39, 50, 101, 110, 111

Vitamin A, 36–37, 180–81Vitamin B-complex, 55, 132–33,

181–83Vitamin C

as antioxidant, 36–37, 101collagen/elastin boosted by, 37–39,

123, 126, 128, 193, 194facials/peels with, 43skin with, 183–84sunspots/discolorations helped by,

76for under-eye area, 39, 50, 101, 110,

111Vitamin D, 184–85Vitamin E, 36–37, 185–86Vitamin K, 50, 73, 132, 186–87

Water, 159–60, 165–66Water content

hyaluronic acid’s impact on, 60menopause’s impact on, 60moisturizer’s impact on, 59–60

Weight, 158–59White tea, 187–88Wrinkles

age-erasing options for, 103–10Botox for, 79–84, 103–7care/prevention for, 54–56repair/protection for, 84–89

YAG lasers, 75–76, 119, 135

Zinc, 189Zyderm, 86, 103, 105Zyplast, 86, 103, 104

210 I N D E X

By the Founder of mdskincare

D E N N I S G R O S S , M . D .

with Cara Kagan

C r e a t e a C u s t o m i z e d P l a n

f o r B E A U T I F U L S K I N

C h o o s e t h e A N T I A G I N G

T r e a t m e n t O p t i o n s T h a t

A r e R i g h t f o r Y o u

YOUR FUTURE FACE

“With all the products out there, what’s a girl to do? Dr. Gross is amazing and he has the answer.” —PLUM SYKES, author of Bergdorf Blondes

Author photo by Jeffrey Weir

ISBN 0-452-28718-9

Title Your Future Face

9

780452 287181

51500

EAN

U.S.A. $15.00CAN. $21.00

THESE DAYS, WE’RE BOMBARDED with advances in skin care that promise to turn back the clock and restore our gorgeous, younger-looking skin. Not all treatments work for everyone, and choosing the right products and procedures is more confusing than ever. In Your Future Face, Dr. Dennis Gross, one of the country’s leading dermatologists and founder of the renowned M.D. Skincare® product line, offers an individualized program that will prevent damage, repair, and dramatically enhance the youth and beauty of your skin at any age.

Your Future Face begins with a simple “Skin Lifecycle Quiz” that assesses your skin’s specific vulnerabilities and predicts your future aging pattern. Once you’ve determined your goals, Dr. Gross provides a customized antiaging plan and invaluable advice, including:

Proven antiaging ingredients you can find in affordable products Simple, yet effective nutritional and lifestyle tips How to naturally boost your skin’s firming proteins Whether to use Botox and how to do it safely How to choose the injectable wrinkle filler that is right for you New breakthroughs in noninvasive peels and lasers,

and the benefits of deeper treatments Plastic surgery: pros, cons, and how to avoid it

Treasured by celebrities and beauty insiders alike, Dr. Gross’s unique methods offer the safest and most effective program for your best skin ever.

For more information, visit www.yourfutureface.com

“I only wish my face had read Your Future Face earlier. Read it and get the skin you’ve always dreamed of!” —JOAN HAMBURG, WOR Radio

DEN

NIS G

RO

SS, M.D

.Y

OU

R FU

TUR

E FACE

PLUME

A PLUME BOOKBeautywww.penguin.com

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your future face - dr. dennis gross, md future face “with all the products out ... published by...

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